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WORLDMALARIAREPORT 2010
WORLD MALARIA REPORT
2010WHO Global Malaria Programme
© World Health Organization 2010
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Photo on cover: Adapted from John Stanmeyer/VII
WHO Library Cataloguing-in-Publication Data
World malaria report : 2010.
1.Malaria - prevention and control. 2 Malaria - economics. 3.Malaria - epidemiology. 4.Disease vectors. 5.Insecticide-treated bednets.
6.Antimalarials. 7.Drug resistance. 8.Case management - administration and organization. 9.World health. I.World Health Organization.
ISBN 978 92 4 156410 6 (NLM classification: WC 765)
ContentsStatement by the United Nations Secretary-General ................................................................................................................................................ vForeword: Director-General World Health Organization .......................................................................................................................................viiAcknowledgements .........................................................................................................................................................................................................................viiiAbbreviations ......................................................................................................................................................................................................................................... ixSummary ................................................................................................................................................................................................................................................. xiKey points .............................................................................................................................................................................................................................................xiii
1. Introduction ...............................................................................................................................................................................................................................12. Goals, policies and strategies for malaria control and elimination ..................................................................................3 2.1 Goals and targets for malaria control and elimination .............................................................................................................3 2.2 Malaria control policies and strategies ...................................................................................................................................................4 2.3 Malaria elimination ...................................................................................................................................................................................................6 2.4 Indicators ..........................................................................................................................................................................................................................73. Financing malaria control .........................................................................................................................................................................................11 3.1 Resource requirements ........................................................................................................................................................................................11 3.2 International financing of malaria control .......................................................................................................................................11 3.3 Domestic financing of malaria control ..................................................................................................................................................12 3.4 Category of expenditure by source of funds ....................................................................................................................................13 3.5 Disbursements by country ...............................................................................................................................................................................14 3.6 Disbursements by stage of malaria control ......................................................................................................................................14 3.7 Conclusions ...................................................................................................................................................................................................................154. Vector control ........................................................................................................................................................................................................................17 4.1 ITN policy and implementation ..................................................................................................................................................................17 4.2 IRS policy and implementation ...................................................................................................................................................................23 4.3 Conclusions ...................................................................................................................................................................................................................245. Malaria diagnosis and treatment .......................................................................................................................................................................25 5.1 Diagnosis of malaria..............................................................................................................................................................................................25 5.2 Treatment of malaria ............................................................................................................................................................................................28 5.3 Intermittent preventive treatment ..........................................................................................................................................................33 5.4 Antimalarial drug resistance .........................................................................................................................................................................34 5.5 Conclusions ...................................................................................................................................................................................................................366. Impact of malaria control .........................................................................................................................................................................................39 6.1 Assessing the impact of malaria interventions ............................................................................................................................39 6.2 African Region: high-burden countries ................................................................................................................................................40 6.3 African Region: low-transmission countries ....................................................................................................................................46 6.4 Region of the Americas ......................................................................................................................................................................................48 6.5 South-East Asia Region ......................................................................................................................................................................................50 6.6 European Region .......................................................................................................................................................................................................52 6.7 Eastern Mediterranean Region .....................................................................................................................................................................54 6.8 Western Pacific Region .......................................................................................................................................................................................56 6.9 Malaria elimination and prevention of reintroduction ...........................................................................................................58 6.10 Global estimates of malaria cases and deaths, 2000–2009 ...............................................................................................58 6.11 Conclusions ...................................................................................................................................................................................................................60
PROFILES – 24 high-burden countries .........................................................................................................................................................................63
ANNEXES ...........................................................................................................................................................................................................................................137
WORLD MALARIA REPORT 2010 v
WORLD MALARIA REPORT 2010 vii
Foreword
Dr Margaret Chan, Director-General World Health Organization
The findings in the World Malaria Report 2010 further
strengthen the business case for investing in malaria control.
The accelerated drive to achieve universal coverage with
today’s tools, called for by the United Nations Secretary-
General in 2008, continues to produce results. Nearly 289
million insecticide-treated mosquito nets (ITNs) will have
been delivered to sub-Saharan Africa between 2008 and
2010, enough to protect 578 million people. In Africa, 75
million people, or 10% of the population at risk, were also
protected in 2009 by indoor residual spraying. These are
real achievements.
These prevention efforts are producing a measurable
public health impact. The annual number of malaria cases
and deaths continues to decline, especially in Africa. The
number of countries that have successfully cut their malaria
burden in half over the past decade continues to rise. For
the first time, not a single case of falciparum malaria was
reported in the WHO European Region in 2009. One by one,
we are counting down the number of countries endemic
for malaria. This year alone, I had the honour to certify both
Morocco and Turkmenistan as being free from malaria, and
was able to add the names of these countries to the Official
register of areas where malaria elimination has been achieved.
Major changes in the way we tackle malaria are
occurring quickly. This is the year when we finally declared
that everyone with suspected malaria has a right to a
confirmatory diagnostic test. The time for this change was
overdue. For too long in too many places, fever has been
equated with malaria. No more. Our efforts at prevention
have produced real changes in malaria transmission,
and most cases of fever, even in Africa, are no longer due
to malaria. This is another clear marker of progress, and
another sign of the way control strategies are constantly
being refined. We have inexpensive, quality-assured rapid
diagnostic tests that can be used all the way down to the
community level.
In 2009, more than a third of suspected malaria cases
reported in Africa were confirmed with a diagnostic test,
a dramatic increase from the less than 5% at the beginning
of the decade. A small number of African countries have
been able to rapidly scale up malaria diagnostic testing
at a national level. Not only has this resulted in saving the
unnecessary use of hundreds of thousands of courses of
ACTs annually, but has also allowed for the implementation
of timely and accurate surveillance for malaria. This is a great
leap forward. Only by knowing where our enemy lurks,
identifying the places where we still have malaria, can we
expect to defeat it.
While there is much to celebrate, the data in this report
also underscore the fragility of our progress. Resurgences
of malaria were observed in parts of at least three African
countries. The exact reasons for these sharp increases are
not known, but likely reflect some combination of natural
variation and lapses in control measures. These programme
failures are a pointed reminder of what could happen if
we reduce our vigilance and do not follow through on
our collective commitments. In many ways, sustaining the
high coverage rates with malaria prevention and control
measures may prove even more challenging than having
achieved such coverage in the first place.
We cannot let this momentum slip. Significant recent
gains, though fragile, must be sustained. The international
community needs to ensure sufficient and predictable
global funding to meet ambitious targets set for malaria
control as part of the drive to reach the health-related
Millennium Development Goals by 2015.
The will to sustain the gains that we have made in malaria
must come not only from global health leaders and from
politicians, but from affected communities. If communities
can know the true burden of malaria, and can see the results
of prevention and control efforts, then the will to eliminate
and ultimately eradicate malaria will never fade.
viii WORLD MALARIA REPORT 2010
AcknowledgementsNumerous people contributed to the production of the World Malaria
Report 2010. The following collected and reviewed data from malaria endemic countries: Ahmad Walid Sediqi (Afghanistan); Yava Ricardo (Angola); Ara Keshishyan (Armenia); Viktor Gasimov (Azerbaijan); Mohammad Jahirul Karim (Bangladesh); Kim Bautista (Belize); Yacoubou Imorou Karimou (Benin); Thinley Yongzom (Bhutan); Marcos Ysrael Fernandez Encinas (Bolivia (Plurinational State of)); Simon Chihanga (Botswana); Oscar Mesones Lapouble (Brazil); Patrice Combary (Burkina Faso); Mbanye Hypax (Burundi); Duong Socheat (Cambodia); Célestin Kouambeng (Cameroon); Antonio Lima Moreira (Cape Verde); M'bary Siolo Mada Bebelou (Central African Republic); Moussa Abba Mahamat (Chad); Xia Zhi-Gui (China); Pablo E Chaparro N (Colombia); Amina Yssouf (Comoros); Jean Claude Batia (Congo); José Luis Garcés Fernandez (Costa Rica); San Koffi Moïse (Côte D'ivoire); Benjamin Atua, Kalindula, Baseane (Democratic Republic of The Congo); David Joa Espinal (Dominican Republic); Kim Yun Chol (Democratic People's Republic Of Korea); Johanes Don Bosco (Democratic Republic Of Timor-Leste); Enrique Castro Saavedra (Ecuador); Gloria Nseng Nchama (Equatorial Guinea); Tewolde G/Meskel (Eritrea); Worku Bekele (Ethiopia) National Malaria Control Programme (French Guiana); J. Solange Antimi (Gabon) Momodou Kalleh (Gambia); Merab Iosava (Georgia); Kofi Osae (Ghana); Ilse Gongora (Guatemala); Amadou Sadio Diallo (Guinea); Duarte Falcão (Guinea-Bissau); Karanchand Krishnallal (Guyana); National Malaria Control Programme (Haiti); Martin Ivan Sinclair (Honduras); GS Sonal (India); Desak Made Wismarini, Mkes (Indonesia); Leila Faraji, Ahmad Raeisi (Iran (Islamic Republic of)); Muthana Ibrahim (Iraq); National Malaria Control Programme (Kenya); Nurbolot Usenbayev (Kyrgyzstan); Kongxay Luang-phengsouk (Lao Peoples Democratic Republic) Tolbert Geewleh Nyenswah (Liberia); Andry Joeliarijaona Rakotorahalahy (Madagascar); Misheck Luhanga (Malawi); Christina Rundi (Malaysia); Klenon Traoré (Mali); Ba Mamadou Dit Dialaw (Mauritania); Héctor Olguín Bernal (Mexico); Samuel Jose Alves Mabunda (Mozambique); Khin Mon Mon (Myanmar); P. Uusiku Uupindi (Namibia); GD Thakur (Nepal); Rolando Francisco Lopez Ampie (Nicaragua); Maazou Abani (Niger); EBA Coker (Nigeria); Muhammad Suleman Memon (Pakistan); Raul Medina (Panama); Leo Sora Makita (Papua New Guinea); Blanca Cousiño, Cynthia Viveros, Beatriz Espinola (Paraguay); Mario Baquilod (Philippines); Division Of Communicable Disease Control (Republic of Korea); Alla Baranova (Russian Federation); Corine Karema (Rwanda); Herodes S. Rompão (Sao Tome and Principe); Mohammed Alzahrani (Saudi Arabia); Mame Birame Diouf (Senegal); Musa Sillah-Kanu (Sierra Leone); Boaz Leornard (Solomon Islands); Fahmi E. Yusuf (Somalia); E Misiani, B Shandukani, Ma Groepe (South Africa); S. L. Deniyage (Sri Lanka); Abd Alla Ahmed Ibrahim Mohd (Sudan (North)); Robert Gama Hassan (Sudan (South)); Simon P. Kunene (Swaziland); Tagaikulov Boturkhon (Tajikistan); Saowanit Vijaykadga (Thailand); Liyè Ayo (Togo); Seher Topluoglu (Turkey); Sofia Aliyeva (Turkmenistan); Ebony Quinto (Uganda); Frank Chacky (United Republic of Tanzania (Mainland)); Abdullah Ali, Abdul-Wahid Al-Mafazy (United Republic of Tanzania (Zanzibar)); Tyo Inna, Lebedeva Natalya, Umarova P.H., Khusainova N. (Uzbekistan); George Taleo (Vanuatu); Nguyen Quang Thieu (Viet Nam); Adel Nasser Aljasari (Yemen); Freddie Masaninga; Mercy Mwanza (Zambia); National Malaria Control Programme (Zimbabwe); Jean Bosco Ahoranyezu (WHO/Rwanda); Henok Kebede Ejigu (WHO/Ethiopia); Derege Olana (WHO/Ethiopia); Rachel Eersel (WHO/Suriname); Gustavo Bretas (WHO/Ecuador); Aida Soto (WHO/Nicaragua); Antonieta Arias (WHO/Paraguay); Marco Fidel Suarez (WHO/Bolivia); Abdur Rashid (WHO/Cambodia); Xiaodong Zhang (WHO/China); Deyer Gopinath (WHO/LaoPDR); Harpal Singh (WHO/Malaysia); Zaixing Zhang (WHO/Papua New Guinea); Jeffrey Hii (WHO/Philippines); Jeunessa Sto Nino (WHO/Philip-pines); Larbi Kwabena (WHO/Solomon Islands); Walter Kazadi Mulombo (WHO/Solomon Islands); Nam Hee Chung (WHO/Republic of Korea); Lasse Vestergaard (WHO/Vanuatu); Dai Tran Cong (WHO/Viet Nam).
The following WHO staff in regional and subregional offices assisted in the design of data collection forms, the collection and validation of data, reviewed epidemiological estimates and country profiles, and prepared country vignettes: Nathan Bakyaita (AFRO); Etienne Magloire Minkoulou (AFRO); Georges Alfred Ki-Zerbo (AFRO); Amadou Bailo Diallo (AFRO/central IST); Khoti Gausi (AFRO/eastern and southern Inter-Country Support Team, ICST); Samson Katikiti (AFRO/ eastern and southern ICST); Abderrahmane Kharchi (AFRO/western IST); Jean-Olivier Guintran (AFRO/western IST); Rainier Escalada (AMRO); Prabjhat Singh (AMRO); Keith Carter (AMRO); Ghasem Zamani (EMRO); Amir Aman (EMRO/DCD/MCE); Hoda Atta (EMRO); Elkhan Gasimov (EURO); Karen Taksøe-Vester (EURO); Mikhail Ejov (EURO); Rakesh Rastogi (SEARO); Krongthong Thimasarn (SEARO); Bayo Fatunmbi (WPRO); Raymond Mendoza (WPRO) and Eva-Maria Chris-tophel (WPRO).
Joshua Yukich of Tulane University undertook data analysis and prepared text for Chapter 3 on malaria financing. Manoj Menon of the US Centers for Disease Control undertook analysis of household survey data on ITN coverage in Chapter 4 on vector control. Abraham Flaxman, Nancy Fullman and Stephen Lim at the Institute of Health Metrics and Evaluation, University of Washington (USA) produced estimates of ITN coverage for African countries using data from household surveys, ITN deliveries by manufacturers and ITNs distributed by NMCPs. Tanya Shewchuk and others from ACT Watch prepared analysis and text on the availability of parasitological diagnosis and antimalarial medicines in Chapter 5 on diagnosis and treatment. Staff from the Global Fund assisted in the conduct of rapid impact assessments presented in Chapter 6 on the impact of malaria control. Madeleine Thomson, Pietro Ceccato, and Michael Bell at International Research Institute for Climate and Society, The Earth Institute at Columbia University, New York, and Hannah Gould and Steve Yoon at Centers for Disease Control and Prevention, Atlanta prepared analysis of the relationship between climate and disease trends in selected African countries. Li Liu, Hope Johnson, Jamie Perin and Bob Black of Johns Hopkins University, Baltimore, prepared estimates of malaria mortality for children living in sub-Saharan Africa. Colin Mathers (WHO) assisted in aligning the estimates of malaria deaths with the Global Burden of Disease Project.
Erin Eckert (Macro International Inc.), Rick Steketee (Malaria Control and Evaluation Partnership in Africa), Mathew Blakley, Ryuichi Komatsu, Eline Korenromp, Estifanos Shargie (Global Fund) reviewed drafts of chapters and made suggestions for their improvement.
The World Malaria Report 2010 was produced by Maru Aregawi, Richard Cibulskis, Yosuke Kita, Mac Otten, and Ryan Williams on behalf of the WHO Global Malaria Programme. Other colleagues in the Global Malaria Programme also contributed to the production of chapters: Amy Barrette, David Bell, Andrea Bosman, Jo Lines, Kamini Mendis, Jose Nkuni, Sivakumaran Murugasampillay, Robert Newman, Peter Olumese, Aafje Rietveld, Pascal Ringwald, Silvia Schwarte. We also thank Lindsay Martinez for editing, and Simone Colairo-Valerio, Anne Damnon and Joan Griffith for administrative support.
Funding for the production of this Report was gratefully received from Amelior Foundation, the Global Fund, the Government of Japan, the Roll Back Malaria Partnership, and the United States Agency for International Development.
WORLD MALARIA REPORT 2010 ix
AbbreviationsABER Annual blood examination rate
ACT Artemisinin-based combination therapy
AIDS Acquired immunodeficiency syndrome
AMFm Affordable Medicine Facility – malaria
AMP Alliance for Malaria Prevention
API Annual parasite incidence
CDC US Centers for Disease Control and Prevention
CHERG WHO Child Health Epidemiology Reference Group
DDT Dichloro-diphenyl-trichloroethane
DHS Demographic and health survey
G6PD Glucose-6-phosphate dehydrogenase
GBD Global burden of disease
Global Fund The Global Fund to fight AIDS, Tuberculosis and Malaria
GMP Global Malaria Programme, WHO
HIV Human immunodeficiency virus
HMIS Health management information system
IAEG Inter-Agency and Expert Group on MDG Indicators
IEC Information, education and communication
IHME Institute for Health Metrics and Evaluation
IPTi Intermittent preventive treatment in infants
IPTp Intermittent preventive treatment in pregnancy
IRS Indoor residual spraying
ITN Insecticide-treated mosquito nets
LLIN Long-lasting insecticide-treated mosquito nets
MDG Millennium Development Goal
MERG RBM Monitoring and evaluation reference group
MICS Multiple indicator cluster survey
MIS Malaria indicator survey
NGO Nongovernmental organization
NMCP National malaria control programme
ODA Official development aid
OECD Organisation for Economic Co-operation and Development
PATH Program for Appropriate Technology in Health
PMI The US President’s Malaria Initiative
RBM Roll Back Malaria Partnership
RDT Rapid diagnostic test
SP Sulfadoxine-pyrimethamine
SPR Slide positivity rate
SUFI Scaling Up for Impact
U5MR Under five mortality rate
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
VAMCM Verbal autopsy multi-cause model
WER Weekly Epidemiological Record
WHA World Health Assembly
WHOPES WHO Pesticide Evaluation Scheme
Abbreviations of antimalarial medicines
AQ Amodiaquine
AL Artemether-lumefantrine
AM Artemether
ART Artemisinin
AS Artesunate
CL Clindamycin
CQ Chloroquine
D Doxycycline
DHA Dihydroartemisinin
MQ Mefloquine
NQ Naphroquine
PG Proguanil
PPQ Piperaquine
PQ Primaquine
PYR Pyronaridine
QN Quinine
SP Sulfadoxine-pyrimethamine
T Tetracycline
(d) Days on treatment course
Abbreviations of WHO Regions / Of fices
AFRO: WHO Regional Office for Africa
AMRO: WHO Regional Office for the Americas
EMRO: WHO Regional Office for the Eastern Mediterranean
EURO: WHO Regional Office for Europe
SEARO: WHO Regional Office for South-East Asia
WPRO: WHO Regional Office for the Western Pacific
WORLD MALARIA REPORT 2010 xi
SummaryThe World Malaria Report 2010 summarizes information received
from 106 malaria-endemic countries/areas and other partners and
it updates the analyses presented in the 2009 Report. It highlights
continued progress made towards meeting international targets for
malaria control to be achieved by 2010 and 2015. The report outlines the
evolving situation of financing for malaria control, how these growing
resources have resulted in increased coverage of WHO-recommended
malaria control interventions, and the association between this rapid
scale-up and substantial reductions in malaria burden.
International funding for malaria control has risen steeply in the
past decade. Disbursements reached their highest ever levels in 2009
at US$ 1.5 billion, but new commitments for malaria control appear
to have stagnated in 2010, at US$ 1.8 billion. Countries with smaller
populations at risk continue to receive more funding per person at risk
than more populous countries. The amounts committed to malaria,
while substantial, still fall short of the resources required for malaria
control, estimated at more than US$ 6 billion for the year 2010.
The increased financing has resulted in tremendous progress in
increasing access to insecticide-treated mosquito nets (ITNs) in the
past 3 years. By the end of 2010, approximately 289 million ITNs will
have been delivered to sub-Saharan Africa, enough to cover 76% of
the 765 million persons at risk of malaria. It is estimated that 42% of
households in Africa owned at least one ITN in mid-2010, and that
35% of children slept under a ITN. The percentage of children using
ITNs is still below the WHA target of 80% partly because up to the end
of 2009, ITN ownership remained low in some of the largest African
countries. Low rates of use reported in some surveys are primarily
due to a lack of sufficient nets to cover all household members;
household survey results suggest that most (80%) of the available
ITNs are used.
While the rapid scale-up of ITN distribution in Africa represents an
enormous public health achievement, it also represents a formidable
challenge for the future in ensuring that the high levels of coverage are
maintained. The lifespan of a long-lasting ITN is currently estimated
to be 3 years. Nets delivered in 2006 and 2007 are therefore already
due for replacement, and those delivered between 2008 and 2010
soon will be. Failure to replace these nets could lead to a resurgence
of malaria cases and deaths.
IRS programmes have also expanded considerably in recent years,
with the number of people protected in sub-Saharan Africa increas-
ing from 13 million in 2005 to 75 million in 2009, corresponding to
protection for approximately 10% of the population at risk in 2009.
Current methods of malaria vector control are highly dependent
on a single class of insecticides, the pyrethroids, which are the most
commonly used compounds for IRS and the only insecticide class
used for ITNs. The widespread use of a single class of insecticides
increases the risk that mosquitoes will develop resistance, which
could rapidly lead to a major public health problem. The risk is of
particular concern in Africa, where insecticidal vector control is being
deployed with unprecedented levels of coverage and where the
burden of malaria is greatest.
WHO now recommends that all cases of suspected malaria be
confirmed with a diagnostic test prior to treatment. As the incidence
of malaria decreases through much of sub-Saharan Africa, the need
to differentiate malaria from non-malarial fevers becomes more
pressing. The proportion of reported cases in Africa confirmed with
a diagnostic test has risen substantially from less than 5% at the
beginning of the decade to approximately 35% in 2009, but low
rates persist in the majority of African countries and in a minority of
countries in other regions. A small number of countries have shown
that it is possible to scale up rapidly the availability of malaria diag-
nostic testing on a national scale, provided that attention is given to
adequate preparation, training, monitoring, supervision and quality
control. Such experiences have been linked with large savings in
the use of artemisinin-based combination therapies (ACTs) and with
improved malaria surveillance.
Information from manufacturers indicates that the number of
ACTs procured has increased in every year since 2005. By the end of
2009, 11 African countries were providing sufficient courses of ACTs
to cover more than 100% of malaria cases seen in the public sector;
a further 8 African countries delivered sufficient courses to treat
50%–100% of cases. These figures represent a substantial increase
since 2005, when only 5 countries were providing sufficient courses
of ACT to cover more than 50% of patients treated in the public
sector. However, information on access to treatment is generally
incomplete, particularly for the significant proportion of patients
treated in the private sector.
The use of oral artemisinin-based monotherapies threatens
the therapeutic life of ACTs by fostering the spread of resistance to
artemisinins. By November 2010, 25 countries were still allowing
the marketing of these products and 39 pharmaceutical companies
were manufacturing them. Most of the countries that still allow the
marketing of monotherapies are located in the African Region and
most of the manufacturers are in India.
The spread of resistance to antimalarial medicines over the past
few decades has led to an intensification of efficacy monitoring to
allow early detection of resistance. Despite the observed changes
in parasite sensitivity to artemisinins, the clinical and parasitological
efficacy of ACTs has not yet been compromised, even in the Greater
Mekong sub-region. Nonetheless, both components of the drug
combination are currently at risk and using an ACT with an ineffec-
tive partner medicine can increase the risk of development or spread
of artemisinin resistance.
A total of 11 countries and one area in the WHO African Region
showed a reduction of more than 50% in either confirmed malaria
cases or malaria admissions and deaths in recent years. A decrease of
more than 50% in the number of confirmed cases of malaria between
2000 and 2009 was found in 3 of the 56 malaria-endemic countries
outside Africa, while downward trends of 25%–50% were seen in 8
other countries. Morocco and Turkmenistan were certified by the
Director-General of WHO in 2010 as having eliminated malaria.
1
xii WORLD MALARIA REPORT 2010
In 2009, the European Region reported no locally acquired cases
of P. falciparum malaria for the first time.
It is estimated that the number of cases of malaria rose from 233
million in 2000 to 244 million in 2005 but decreased to 225 million
in 2009. The number of deaths due to malaria is estimated to have
decreased from 985 000 in 2000 to 781 000 in 2009. Decreases in
malaria burden have been observed in all WHO Regions, with the
largest proportional decreases noted in the European Region,
followed by the Region of Americas. The largest absolute decreases
in deaths were observed in Africa.
While progress in reducing the malaria burden has been remark-
able, there was evidence of an increase in malaria cases in 3 countries
in 2009 (Rwanda, Sao Tome and Principe, and Zambia). The reasons
for the resurgences are not known with certainty. The increases in
malaria cases highlight the fragility of malaria control and the need
to maintain control programmes even if numbers of cases have been
reduced substantially. The experiences in Rwanda and Zambia also
indicate that monthly monitoring of disease surveillance data, both
nationally and subnationally, is essential. Since many countries in
sub-Saharan Africa had inadequate data to monitor disease trends,
it is apparent that greater efforts need to be made to strengthen
routine surveillance systems. Major epidemiological events could be
occurring in additional countries without being detected and inves-
tigated.
Key points
Background and contextMalaria-endemic countries and the global community are scaling up effective interventions to attain both coverage and impact targets for 2010 and beyond.
1. On World Malaria Day 2008, the United Nations Secretary-Gen-
eral called for efforts to ensure universal coverage with malaria
prevention and treatment programmes by the end of 2010.
2. The goal established by the World Health Assembly in 2005
and by the Roll Back Malaria (RBM) Partnership is to reduce the
numbers of malaria cases and deaths recorded in 2000 by 50% or
more by the end of 2010 and by 75% or more by 2015.
3. In September 2008, the RBM Partnership launched the Global
Malaria Action Plan, which defines the steps required to acceler-
ate achievement of the 2010 and 2015 targets for malaria control
and elimination.
Policies and strategies for malaria controlTo attain the 2010 and 2015 targets, countries must reach all persons at risk for malaria with an insecticide-treated mosquito net (ITN) or indoor residual spraying (IRS) and provide laboratory-based diagnosis for all suspected cases of malaria and effective treatment of all confirmed cases.
Prevention
4. In 2009, 23 countries in the WHO African Region and 42 in other
WHO Regions had adopted the WHO recommendation to
provide ITNs for all persons at risk for malaria, not just women
and children; this represents an increase of 13 countries since
2008. A total of 83 countries, of which 39 are in the African Region,
distribute ITNs free of charge.
5. IRS with WHO-approved chemicals (including DDT) remains one
of the main interventions for reducing and interrupting malaria
transmission by vector control in all epidemiological settings. In
2009, 71 countries, including 27 in the African Region, reported
implementation of IRS and 17 countries reported using DDT for
IRS.
6. Intermittent preventive treatment (IPT) is recommended for
population groups in areas of high transmission who are particu-
larly vulnerable to contracting malaria or suffering its conse-
quences, particularly pregnant women and infants. A total of 35
of 45 sub-Saharan African countries had adopted IPT for pregnant
women (IPTp) as national policy by the end of 2008. Papua New
Guinea, in the Western Pacific Region, also adopted this policy
in 2009. No country has yet adopted a national policy of IPT for
infants (IPTi).
Diagnosis and treatment
7. Prompt parasitological confirmation by microscopy or with a
rapid diagnostic test (RDT) is recommended for all patients with
suspected malaria, before treatment is started. In 2008, 33 of 43
malaria-endemic countries in the African Region and 45 of 63
countries in other Regions reported having a policy of parasito-
logical testing of suspected malaria cases in persons of all ages,
and 77 of 86 countries with endemic Plasmodium falciparum
reported a policy of treatment with an artemisinin-based combi-
nation therapy (ACT) for P. falciparum malaria.
8. Confirmed cases of uncomplicated P. falciparum malaria should
be treated with an ACT. P. vivax malaria should be treated with
chloroquine where it is effective, or an appropriate ACT in areas
where P. vivax is resistant to chloroquine. Treatment of P. vivax
should be combined with a 14-day course of primaquine to
prevent relapse.
9. WHO recommends that oral artemisinin-based mono therapies
be withdrawn from the market and replaced with ACTs. By
November 2010, 25 countries were still allowing the marketing of
these products (down from 37 in 2009) and 39 pharmaceutical
companies were manufacturing them. Most of the countries that
still allow the marketing of monotherapies are in the African
Region, while most of the manufacturers of these medicines are
in India.
Financing malaria control The funds committed to malaria control from international sources have increased consistently between 2004 and 2009; funds remained at US$ 1.8 billion in 2010, substantially lower than the resources required to achieve global targets, estimated at more than US$ 6 billion for the year 2010.
10. International funds disbursed for malaria control are estimated
to have increased from US$ 200 million in 2004 to US$ 1.5 billion
million in 2009. Spending by national governments on malaria
control appears to have risen in all WHO Regions between 2004
and 2009; thus large increases in donor financing do not appear
to have resulted in an overall reduction in the level of domestic
financing, although countries which had reduced their spending
received more external financing than those which had increased
their domestic spending on malaria.
11. Of 106 malaria-endemic countries and areas, 77 received external
assistance for malaria control between 2000 and 2008. The
highest per capita expenditure continued to be seen in countries
with smaller populations at risk. External financing appears to be
concentrated on programme activities, particularly the procure-
ment of ITNs, antimalarial medicines and IRS. A larger proportion
WORLD MALARIA REPORT 2010 xiii
xiv WORLD MALARIA REPORT 2010
of national government financing is directed towards human
resources although significant amounts are also spent on anti-
malarial medicines and IRS.
12. Countries in the pre-elimination and elimination phases appear
to spend more per person at risk of malaria than countries in
the control phase. While the additional spending is partly due
to larger amounts of external financing, government financing
exceeds that of external financing in countries in the pre-elimi-
nation and elimination stages.
Progress in preventing malariaCoverage with ITNs is increasing rapidly in some countries of Africa, household ITN ownership having risen to 42% by mid-2010.
13. In less than 3 years between 2008 and 2010 a cumulative total of
254 million ITNs were delivered to sub-Saharan Africa, enough
to cover 66% of the 765 million persons at risk. An additional
35 million ITNs are scheduled for delivery before the end of
2010, sufficient to cover a further 10% of the population at risk.
However, considerably more work is required to ensure that ITNs
reach all households where they are needed, and that persons at
risk of malaria sleep under an ITN every night.
14. A model-based estimate showed that 42% of African households
owned at least one ITN, and 35% of children < 5 years of age slept
under an ITN in 2010. Household ITN ownership was estimated
in this model to have reached ≥ 50% in 19 African countries in
2010.
15. Household surveys undertaken between 2007 and 2009 found
that 11 countries (Equatorial Guinea, Ethiopia, Gabon, Mali,
Rwanda, Senegal, Sao Tome and Principe, Senegal, Sierra Leone,
Togo, and Zambia) had reached a household ITN ownership rate
of more than 50%. The median percentage of children < 5 years
of age sleeping under an ITN in these countries was 45%. Low
rates of use reported in some surveys are primarily due to a lack
of sufficient nets to cover all household members; a very high
proportion (80%) of available ITNs is used.
16. Persons aged 5–19 years are least likely to use an ITN compared
to those in the younger and older age groups. Women are
slightly more likely to sleep under an ITN than men (ratio women:
men = 1.1); this is partly because pregnant women are more likely
to sleep under an ITN than other women. There is no difference
in usage rates between female and male children < 5 years of age
(ratio girls: boys = 0.99).
17. The number of people protected by IRS increased in sub-Saharan
Africa from 13 million in 2005 to 75 million in 2009, a quantity
which corresponds to protection for 10% of the population at risk
in 2009.
18. In other WHO Regions, the number of ITNs delivered by manu-
facturers or distributed by NMCPs is smaller than in Africa
(16.4 million 2009), but has been increasing at a similar rate.
IRS implementation is relatively stable with 98 million people
protected in 2009 (69 million in India). With the exception of
India, the proportion of the population protected by IRS tends
to be smaller than in the African countries which use IRS, possibly
because of the more focal nature of malaria outside Africa.
19. Current methods of malaria control are highly dependent on a
single class of insecticides, the pyrethroids, which are the most
commonly used compounds for IRS and the only insecticide class
used for ITNs. The widespread use of a single class of insecticide
increases the risk that mosquitoes will develop resistance, which
could rapidly lead to a major public health problem, particularly
in Africa, where chemical vector control is being deployed with
unprecedented levels of coverage and where the burden of
malaria is greatest.
Progress on the prevention of malaria during pregnancyCoverage with intermittent preventive treatment for pregnant women (IPTp) remains far from target levels, although a few countries have made notable progress.
20. The percentage of pregnant women who received the second
dose of IPTp ranged from 2.4% in Angola to 62% in Zambia,
according to households surveys in 8 countries for which data
were available for 2007–2009. The weighted average, repre-
senting a population of 270 million, remained low, at 12%, due
primarily to low coverage rates in Nigeria.
21. Data reported by NMCPs in 22 high-burden countries in the
African Region indicate that the percentage of women attending
antenatal clinics who received the second dose of IPTp was 55%
(inter-quartile range 47%–61%).
Progress in the diagnosis and treatment of malaria The number of RDTs and ACTs procured is increasing, and the percentage of reported suspected cases receiving a parasitological test has increased from 67% globally in 2005 to 73% in 2009. Many cases still are treated without a parasitological diagnosis.
22. The percentage of reported suspected malaria cases receiving a
parasitological test has increased between 2005 and 2009, partic-
ularly in the African Region (from 26% to 35%), Eastern Mediterra-
nean Region (47% to 68%) and South-East Asia Region excluding
India (from 58% to 95%). Low rates persist in the majority of
African countries: in 21 out of 42 countries which reported on
testing, the percentage of cases tested was less than 20%. Data
from a limited number of countries suggest that both microscopy
and RDTs are less widely available in the private sector than the
public sector.
23. A small number of countries, including the Lao People’s Demo-
cratic Republic and Senegal, have shown that it is possible to
scale up rapidly the availability of malaria diagnostic testing
nationwide, provided that attention is given to adequate prepa-
ration, training, monitoring, supervision and quality control.
WORLD MALARIA REPORT 2010 xv
24. The number of ACT treatment courses procured increased greatly
from 11.2 million in 2005 to 76 million in 2006, and reached 158
million in 2009. By the end of 2009, 11 African countries were
providing sufficient courses of ACTs to cover more than 100%
of malaria cases seen in the public sector; a further 8 African
countries delivered sufficient courses to treat 50%–100% of
cases. These figures represent a substantial increase since 2005,
when only 5 countries were providing sufficient courses of ACT
to cover more than 50% of patients treated in the public sector.
However, the number of ACTs distributed by NMCPs in the African
Region in 2009 exceeded the number of RDTs procured more
than five-fold, and the total number of tests carried out (micros-
copy + RDTs) by a factor of 2.4, indicating that many patients are
receiving ACTs without confirmatory diagnosis.
25. By combining household survey data with health facility data it
can be estimated that, on average, 65% of treatment needs are
fulfilled for patients attending public health facilities. Estimates
are more difficult to construct for patients who are treated in the
private sector, but household surveys indicate febrile patients
treated in the private sector are 25% less likely to receive an anti-
malarial than those visiting public sector facilities, while those
that stay at home are 60% less likely.
26. The use of oral artemisinin-based monotherapies threatens
the therapeutic life of ACTs by fostering the spread of resist-
ance to artemisinin. By November 2010, 25 countries were still
allowing the marketing of these products and 39 pharmaceuti-
cal companies were manufacturing these products. Most of the
countries that still allow the marketing of monotherapies are
located in the African Region and most of the manufacturers are
in India.
27. Parasite resistance has rendered previous antimalarial medicines
ineffective in most parts of the world, jeopardizing malaria
control. The highly effective artemisinin derivatives and their
partner drugs are vulnerable to the same risk. Resistance of
P. falciparum to artemisinins was confirmed at the Cambodia-
Thailand border in 2009 but despite the observed changes in
parasite sensitivity to artemisinins, the clinical and parasitologi-
cal efficacy of ACTs has not yet been compromised. Since 2008,
containment activities to limit the spread of artemisinin-resistant
parasites have been ongoing.
Impact of malaria controlA growing number of countries have recorded decreases in the number of confirmed cases of malaria and/or reported admissions and deaths since 2000. Global control efforts have resulted in a reduction in the estimated number of deaths from nearly 1 million in 2000 to 781 000 in 2009.
28. A total of 11 countries and one area in the African Region showed
a reduction of more than 50% in either confirmed malaria cases or
malaria admissions and deaths in recent years (Algeria, Botswana,
Cape Verde, Eritrea, Madagascar, Namibia, Rwanda, Sao Tome
and Principe, South Africa, Swaziland, Zambia, and Zanzibar,
United Republic of Tanzania). In all countries, the decreases are
associated with intense malaria control interventions.
29. In 2009 there was evidence of an increase in malaria cases in three
countries that had previously reported reductions (Rwanda, Sao
Tome and Principe, and Zambia). The reasons for these resur-
gences are not known with certainty, but they highlight the
fragility of progress in malaria control and the need to rigor-
ously maintain control programmes even when cases have been
reduced substantially.
30. In other WHO Regions, the number of reported cases of confirmed
malaria decreased by more than 50% in 3 of the 56 malaria-en-
demic countries between 2000 and 2009 and downward trends
of 25%–50% were seen in 8 other countries. In 2009, the European
Region reported no locally acquired cases of P. falciparum malaria
for the first time. The number of cases fell least in countries with
the highest incidence rates, indicating that greater attention
should be given to countries which harbour most of the malaria
burden outside Africa.
31. There were 8 countries in the pre-elimination stage of malaria
control in 2009 and 10 countries are implementing elimination
programmes nationwide (6 having entered the elimination phase
in 2008). A further 9 countries (Armenia, Bahamas, Egypt, Jamaica,
Morocco, Oman, Russian Federation, Syrian Arab Republic, and
Turkmenistan) are in the phase of preventing re-introduction
of malaria. Morocco and Turkmenistan were certified as free of
malaria by the WHO Director-General in 2010.
32. It is estimated that the number of cases of malaria rose from 233
million in 2000 to 244 million in 2005 but decreased to 225 million
in 2009. The number of deaths due to malaria is estimated to have
decreased from 985 000 in 2000 to 781 000 in 2009. Decreases in
malaria burden have been observed in all WHO Regions, with the
largest proportional decreases noted in the European Region,
followed by the Region of the Americas. The largest absolute
decreases in deaths were observed in Africa.
1
xvi WORLD MALARIA REPORT 2010
Avant-propos
Dr Margaret Chan, Directeur général de l’Organisation mondiale de la Santé
L’analyse de rentabilité que l’on peut faire à la lumière
des conclusions du Rapport 2010 sur le paludisme dans le monde apporte des arguments supplémentaires en faveur
d’un investissement dans la lutte antipaludique. L’accélération
du mouvement en vue d’assurer une couverture universelle
au moyen des dispositifs actuels, que le Secrétaire général
des Nations Unies a appelée de ses vœux en 2008, continue
de porter ses fruits. Entre 2008 et 2010, près de 289 millions
de moustiquaires imprégnées d’insecticide (MII) auront été
fournies à l’Afrique subsaharienne, un nombre suffisant pour
protéger 578 millions de personnes. En Afrique, 75 millions
de personnes, soit 10 % de la population exposée au risque,
ont également été protégées grâce à des pulvérisations
intradomiciliaires d’insecticides à effet rémanent (PID). Ce sont
là des résultats concrets.
Cet effort de prévention a des conséquences mesurables
en termes de santé publique. Le nombre de cas et de décès
imputables chaque année au paludisme poursuit son déclin,
notamment en Afrique. Les pays qui sont parvenus à réduire de
moitié leur charge de morbidité palustre au cours de la dernière
décennie sont toujours plus nombreux. Pour la première fois,
aucun cas de paludisme à falciparum n’a été signalé en 2009
dans la Région OMS de l’Europe. Nous voyons le nombre
des pays d’endémie palustre se réduire pays par pays. Rien
que cette année, j’ai eu l’honneur de certifier le Maroc et le
Turkménistan exempts de paludisme et j’ai pu inscrire ces pays
au Registre des zones où l’élimination du paludisme a été réalisée.
Des changements majeurs sont en train de faire évoluer
rapidement notre façon de nous attaquer au paludisme. Cette
année, nous avons enfin déclaré que tout cas suspect de
paludisme avait droit à un diagnostic de confirmation. Il était
grand temps de le faire. On a trop longtemps et en trop de lieux
assimilé chaque cas de fièvre à un cas de paludisme. Ce temps
est révolu. Nos efforts de prévention ont réellement modifié la
transmission du paludisme et même en Afrique, la plupart des
cas de fièvre ne sont plus dus au paludisme. Voilà encore un
signe indiscutable de progrès qui traduit le perfectionnement
constant de nos stratégies de lutte. Nous disposons de tests
de diagnostic rapide, peu coûteux, de qualité garantie et qui
peuvent être effectués à tous les niveaux, et même à celui de la
communauté.
En 2009, plus d’un tiers des cas suspectés de paludisme
notifiés en Afrique ont été confirmés par un test de diagnostic,
ce qui représente une augmentation spectaculaire par rapport
aux moins de 5 % que l’on enregistrait au début de la décennie.
Dans un petit nombre de pays africains, on est parvenu à passer
rapidement à l’échelon national en matière de diagnostic.
Cela a permis non seulement d’économiser chaque année
des milliers de traitements inutiles à l’aide d’associations
thérapeutiques à base d’artémisinine (ACT), mais encore
de donner les moyens de surveiller le paludisme en temps
opportun et de manière fiable. C’est là une importante avancée.
Ce n’est qu’en découvrant où se cache l’ennemi, en localisant les
zones où il sévit encore, que nous pouvons espérer le vaincre.
S’il est vrai qu’il y a lieu de se réjouir, les données qui figurent
dans ce rapport mettent en évidence la fragilité de nos progrès.
Une résurgence du paludisme a été observée dans certaines
zones d’au moins trois pays africains. Les raisons de cette forte
augmentation ne sont pas connues avec exactitude, mais
elles tiennent probablement à la conjugaison de variations
naturelles et de défaillances dans les mesures de lutte. Ces
échecs programmatiques nous rappellent ce qui pourrait
arriver en devenant moins vigilants ou en ne donnant pas
suite à nos engagements collectifs. A bien des égards, plus que
d’être déjà parvenus à assurer un taux élevé de couverture par
des mesures de prévention et de lutte antipalustre, c’est d’en
assurer la durabilité qui risque de poser problème.
Nous ne pouvons pas laisser cette dynamique s’essouffler.
Nos récents acquis sont importants mais fragiles et nous
devons les pérenniser. Il faut que la communauté internationale
assure, au niveau mondial, un financement qui soit à la
fois prévisible et suffisant pour atteindre, dans le cadre des
efforts déployés en vue de la réalisation en 2015 des objectifs
sanitaires du millénaire pour le développement, les cibles
ambitieuses qui ont été fixées en matière de lutte contre le
paludisme.
Il faut que la volonté de maintenir les acquis de la lutte
antipaludique émane non seulement des chefs de file de
l’action sanitaire mondiale ou des responsables politiques,
mais aussi des communautés concernées. Pour autant que ces
communautés puissent se rendre compte de la charge réelle
que le paludisme fait peser sur elles et des résultats obtenus
grâce aux efforts déployés pour le prévenir et le juguler, la
volonté d’éliminer et de finir par éradiquer cette maladie ne
faiblira jamais.
WORLD MALARIA REPORT 2010 xvii
Résumé
Le Rapport 2010 sur le paludisme dans le monde récapitule
les informations communiquées par les 106 pays d’endémie
palustre, ou émanant d’autres sources, et il met à jour les analyses
qui figurent dans le rapport 2009. Il met en lumière les progrès
ininterrompus accomplis vers la réalisation, en 2010 et 2015, des
objectifs internationaux en matière de lutte antipaludique. Le
rapport évoque également les changements intervenus dans la
situation financière de la lutte antipaludique ; il montre comment
les ressources croissantes dont elle dispose ont permis de diffuser
plus largement les interventions recommandées par l’OMS
et indique en quoi le recul notable de la charge de morbidité
palustre est lié à ce passage rapide à l’échelle supérieure.
Les fonds d’origine internationale consacrés à la lutte
antipaludique ont fortement augmenté au cours de la dernière
décennie. C’est en 2009 que les dépenses ont atteint le montant
le plus élevé jamais observé avec un total de 1,5 milliard US$, mais
les nouveaux engagements en faveur de la lutte antipaludique
ont visiblement stagné en 2010, avec un montant de 1,8 milliard
US$. Les pays dont la population exposée au risque est peu
nombreuse continuent à recevoir davantage de fonds par
personne exposée au risque que les pays plus fortement peuplés.
Les sommes consacrées au paludisme, pour importantes qu’elles
soient, restent insuffisantes au regard des ressources nécessaires
pour combattre la maladie, lesquelles sont évaluées à plus de 6
milliards US$ pour l’année 2010.
Ce financement accru a permis des progrès considérables
dans l’accessibilité des moustiquaires imprégnées d’insecticides
(MII) au cours des trois dernières années. Fin 2010, environ
289 millions de MII ont été fournies à l’Afrique subsaharienne,
un nombre suffisant pour couvrir 76 % des 765 millions de
personnes exposées au risque de paludisme. On estime qu’au
milieu de l’année 2010, 42 % des ménages africains étaient en
possession d’une MII et que 35 % des enfants dormaient sous une
telle moustiquaire. Le pourcentage d’enfants utilisant une MII
est encore inférieur au chiffre de 80 % préconisé par l’Assemblée
mondiale de la Santé, en partie du fait que, jusqu’à fin 2009, il y
avait encore peu de possesseurs de MII dans certains des plus
grands pays d’Afrique. Les faibles taux d’utilisation relevés par
certaines enquêtes s’expliquent principalement par le nombre
insuffisant de moustiquaires pour équiper tous les membres
d’un ménage; les résultats des enquêtes indiquent que la plupart
(80 %) des MII disponibles sont utilisées.
Si la montée en flèche de la distribution de MII en Afrique
représente un exploit considérable sur le plan de la santé
publique, elle n’en constitue pas moins un formidable défi pour
l’avenir, s’agissant du maintien d’un niveau élevé de couverture.
On estime que la durée de vie d’une MII de longue durée
(MILD) est actuellement de 3 ans. Les moustiquaires livrées
en 2006 et 2007 doivent donc déjà être remplacées, et celles
qui ont été livrées en 2008 et 2009 devront l’être bientôt. Le
non remplacement de ces moustiquaires pourrait entraîner la
réapparition de cas et de décès imputables au paludisme.
Les programmes de pulvérisations intradomiciliaires d’insec-
ticides à effet rémanent (PID) ont connu un dévelop pement
très important en Afrique subsaharienne au cours des dernières
années, le nombre de personnes protégées passant de 13
millions en 2005 à 75 millions en 2009, soit un taux de couverture
d’environ 10 % de la population exposée au risque en 2009.
Les méthodes actuelles de lutte antivectorielle dépendent
en très grande partie d’une seule classe d’insecticides, les
pyréthrinoïdes, qui sont les composés les plus couramment
utilisés pour les PID et les seuls qui servent à imprégner les
moustiquaires. En généralisant l’usage d’une seule et unique
classe d’insecticides, on accroît le risque de voir apparaître,
chez les moustiques vecteurs, une résistance qui pourrait
devenir rapidement un problème majeur de santé publique. Ce
risque est particulièrement préoccupant en Afrique, où la lutte
antivectorielle au moyen d’insecticides est actuellement menée
avec des niveaux de couverture sans précédent et où la charge
de morbidité palustre est la plus élevée.
L’OMS recommande désormais que tous les cas suspects
de paludisme soient confirmés par un test de diagnostic
préalablement à tout traitement. Maintenant que l’incidence
du paludisme recule dans une grande partie de l’Afrique
subsaharienne, la nécessité de différencier une fièvre palustre
d’un état fébrile ayant une autre origine se fait plus pressante.
En Afrique, la proportion de cas notifiés comme cas confirmés
par un test de diagnostic a sensiblement augmenté, passant
de moins de 5 % au début de la décennie à environ 35 % en
2009, mais cette proportion reste faible dans la plupart des pays
d’Afrique et dans un petit nombre de pays des autres Régions.
Dans un petit nombre de pays, on a montré qu’il était possible
d’accroître rapidement la disponibilité des tests de diagnostic
rapide à l’échelon national, en veillant à assurer une préparation,
une formation, un suivi, un encadrement et un contrôle de qualité
adéquats. En lien avec ces expériences, il y a eu d’importantes
économies dans l’utilisation des combinaisons thérapeutiques
à base d’artémisinine (CTA) et une meilleure surveillance du
paludisme.
D’après les renseignements communiqués par les
producteurs, le nombre de CTA délivrées augmente chaque
année depuis 2005. Fin 2009, 11 pays africains fournissaient
suffisamment de cures pour traiter plus de 100 % des cas de
paludisme vus dans le secteur public et 8 autres en ont délivré
suffisamment pour traiter de 50 à 100 % des cas. Ces chiffres
traduisent une augmentation notable depuis 2005, année où
seulement 5 pays fournissaient suffisamment de cures pour
xviii WORLD MALARIA REPORT 2010
traiter plus de 50 % des malades pris en charge par le secteur
public. Cela étant, les informations relatives à l’accessibilité du
traitement sont généralement incomplètes, notamment en ce
qui concerne la proportion importante de malades qui sont
traités dans le secteur privé.
Le recours aux monothérapies à base d’artémisinine par
voie orale constitue une menace pour la durée de validité
thérapeutique des CTA, dans la mesure où il favorise la
propagation d’une résistance aux artémisinines. En novembre
2010, la commercialisation de ces produits était encore autorisée
dans 25 pays et 39 firmes pharmaceutiques en fabriquaient. La
plupart des pays où la commercialisation des monothérapies
est encore autorisée appartiennent à la Région de l’Afrique et
presque tous les producteurs se trouvent en Inde.
La résistance aux antipaludéens s’est étendue au cours
des dernières décennies et cela a conduit à surveiller plus
intensément l’efficacité de ces produits afin de déceler dans les
plus brefs délais l’apparition d’une telle résistance. Malgré les
changements que l’on observe dans la sensibilité des plasmodies
aux artémisinines, l’efficacité clinique et parasitologique des
CTA n’est pas encore compromise, même dans la sous-région
du Grand Mékong. Les deux constituants de cette association
médicamenteuse n’en sont pas moins menacés et utiliser une
CTA comportant un médicament associé inefficace peut accroître
le risque de faire apparaître ou de propager la résistance aux
artémisinines.
Il y a 11 pays au total et un territoire dans la Région OMS de
l’Afrique où le nombre des cas confirmés de paludisme ou des
hospitalisations et des décès pour cause de paludisme a reculé
de plus de 50 % au cours de ces dernières années. Entre 2000 et
2009, on a enregistré un recul de plus de 50 % des cas confirmés
de paludisme dans 3 des 56 pays d’endémie palustre situés hors
d’Afrique, une tendance descendante de l’ordre de 25 à 50 %
étant observée dans 8 autres pays. En 2010, le Directeur général
de l’OMS a certifié que le Maroc et le Turkménistan avaient
éliminé le paludisme. La même année et pour la première fois,
aucun cas de paludisme à falciparum n’a été notifié dans la
Région OMS de l’Europe.
On estime que le nombre de cas de paludisme est passé de
233 millions en 2000 à 244 millions en 2005, mais qu’il a reculé
à 225 millions en 2009. Selon les estimations, le nombre de
décès imputables au paludisme a reculé de 985 000, en 2000, à
781 000 en 2009. Une baisse de la charge de morbidité
palustre a été observée dans toutes les Régions de l’OMS.
Proportionnellement, la baisse a été la plus marquée dans la
Région de l’Europe, suivie par la Région des Amériques. En
valeur absolue, c’est en Afrique que le nombre de décès a le plus
reculé.
Si la réduction de la charge de morbidité palustre a remarqua-
blement progressé, on a les preuves d’une augmentation des cas
dans 3 pays en 2009 (Rwanda, Sao Tomé-et-Principe, Zambie).
Les raisons de cette résurgence ne sont pas connues avec
certitude. Cette augmentation des cas de paludisme souligne la
fragilité des acquis de la lutte antipaludique et la nécessité de
maintenir les programmes de lutte même si le nombre de cas a
sensiblement reculé. Ce qui s’est passé au Rwanda et en Zambie
montre également qu’un contrôle mensuel des données fournies
par la surveillance de la morbidité, tant au niveau national qu’au
niveau infranational, est essentiel. Beaucoup de pays de l’Afrique
subsaharienne n’ayant pas suffisamment de données pour suivre
les tendances de la morbidité, il est clair que de grands efforts
sont encore à faire pour renforcer les systèmes de surveillance
systématique. Des événements épidémiologiques majeurs
pourraient se produire dans d’autres pays sans être décelés ni
soumis à investigation.
1
WORLD MALARIA REPORT 2010 xix
Points essentiels
Historique et contexteLes pays d’endémie palustre et la communauté internationale interviennent efficacement et à grande échelle pour atteindre, d’ici 2010 et au-delà, les cibles fixées en matière de couverture et d’impact.
1. Lors de l’appel qu’il a lancé en 2008 à l’occasion de la Journée
mondiale du paludisme, le Secrétaire général des Nations
Unies a souhaité que des efforts soient déployés afin d’assurer
d’ici 2010 une couverture universelle par les programmes de
prévention et de traitement de cette maladie.
2. En 2005, l’Assemblée mondiale de la Santé et le Partena-
riat "Faire reculer le paludisme" (RBM) se sont fixé pour but
de réduire le nombre de cas et de décès imputables au
paludisme d’au moins 50 % d’ici fin 2010 et d’au moins 75 %
d’ici 2015 par rapport aux chiffres de 2000.
3. En septembre 2008, le Partenariat RBM a lancé un Plan
mondial d’action contre le paludisme qui définit les mesures
permettant d’atteindre plus rapidement les cibles fixées
pour 2010 et 2015 en ce qui concerne l’endiguement et l’éli-
mination du paludisme.
Politiques et stratégies de lutte antipaludiquePour atteindre les cibles fixées pour 2010 et 2015, les pays doivent faire en sorte que toutes les personnes exposées au risque de paludisme aient accès aux moustiquaires imprégnées d’insecticide (MII) et aux pulvérisations intradomiciliaires d’insecticides à effet rémanent (PID), que tous les cas suspects de paludisme fassent l’objet d’un diagnostic en laboratoire, et que tous les cas confirmés soient traités efficacement.
Prévention
4. En 2009, 23 pays appartenant à la Région de l’Afrique et 42
pays situés dans d’autres Régions de l’OMS avaient adopté
les recommandations de l’Organisation préconisant la four-
niture de MII à toutes les personnes exposées au risque de
paludisme et pas uniquement aux femmes et aux enfants;
cela représente 13 pays de plus qu’en 2008. Il y a au total 83
pays – dont 39 dans la Région de l’Afrique –, qui distribuent
gratuitement des MII à toutes les personnes exposées au
risque de paludisme.
5. Les pulvérisations intradomiciliaires (PID) à l'aide d’insecti-
cides à effet rémanent agréés par l’OMS (y compris le DDT)
constituent encore la principale mesure de lutte antivecto-
rielle destinée à réduire ou interrompre la transmission du
paludisme dans tous les contextes épidémiologiques. En
2009, 71 pays dont 27 situés dans la Région de l’Afrique, on
indiqué procéder à des pulvérisations intradomicilaires, 17
de ces pays ayant recours au DDT pour ces opérations.
6. Un traitement préventif intermittent (TPI) est recommandé
pour les groupes de population vivant dans des zones à
forte transmission et qui sont particulièrement exposés à
contracter le paludisme ou à souffrir de ses conséquen-
ces, notamment les femmes enceintes et les nourrissons.
Sur 45 pays de l’Afrique subsaharienne, il y en a 35 qui, fin
2008, avaient adopté le TPI comme politique nationale. Dans
la Région du Pacifique occidental, la Papouasie-Nouvelle
Guinée a également adopté cette politique en 2009. Aucun
pays n’a pour l’instant fait du TPI un élément de sa politique
nationale dans le cas des nourrissons.
Diagnostic et traitement
7. Une prompte confirmation parasitologique par examen
microscopique ou au moyen d’un test de diagnostic rapide
(TDR) est recommandée avant tout traitement pour l’ensem-
ble des cas suspects de paludisme. En 2008, 33 des 43 pays
d’endémie palustre situés dans la Région de l’Afrique et 45
des 63 qui font partie d’autres Régions ont indiqué avoir
pour politique de pratiquer des examens parasitologiques
chez les cas suspects de paludisme appartenant à toutes les
classes d’âge et 77 des 86 pays où Plasmodium falciparum est
endémique ont déclaré que leur ligne de conduite était de
traiter le paludisme à falciparum au moyen de combinaisons
thérapeutiques à base d’artémisinine (CTA).
8. Les cas confirmés de paludisme simple à falciparum doivent
être traités au moyen d’une association thérapeutique à base
d’artémisinine. Le paludisme à vivax doit être traité par la
chloroquine là où cet antipaludéen reste efficace ou par une
CTA dans les zones où P. vivax est résistant à la chloroquine.
Le traitement du paludisme à vivax doit être complété par
l’administration de primaquine pendant 14 jours afin d’éviter
les rechutes.
9. L’OMS recommande de retirer du marché les monothérapies
à base d’artémisinine et de les remplacer par des CTA. En
novembre 2010, 25 pays autorisaient encore la commercia-
lisation de ces produits (ils étaient 37 en 2009) et 39 firmes
pharmaceutiques les fabriquaient. La plupart des pays où la
commercialisation des monothérapies est encore autorisée
appartiennent à la Région de l’Afrique, tandis que la plupart
des fabricants de ces médicaments se trouvent en Inde.
xx WORLD MALARIA REPORT 2010
Financement de la lutte antipaludique
Les fonds qui sont affectés à la lutte antipaludique provenant de sources de financement internationales ont régulièrement augmenté entre 2004 et 2009, mais ils ont stagné en 2010 avec un montant de 1,8 milliard US$ et restent sensiblement inférieurs aux ressources nécessaires pour atteindre les cibles fixées au niveau mondial, ressources que l’on évalue à plus de 6 milliards US$ pour l’année 2010.
10. On estime que les fonds internationaux affectés à la lutte
antipaludique sont passés de 200 millions US$ en 2004 à 1,5
milliard US$ en 2009. Il apparaît que les montants dépensés
par les pouvoirs publics nationaux au titre de la lutte contre
le paludisme ont augmenté dans toutes les Régions de l’OMS
entre 2004 et 2009 ; il semble donc que la forte augmenta-
tion des fonds alloués par des donateurs n’ait pas eu pour
effet de réduire globalement le financement par des fonds
nationaux, encore que les pays qui avaient réduit leurs
dépenses aient reçu davantage de fonds extérieurs que ceux
qui avaient consacré davantage de fonds d’origine nationale
à la lutte antipaludique.
11. Entre 2000 et 2008, sur les 106 pays ou territoires d’endémie
palustre, 77 ont reçu une aide extérieure au titre de la lutte
contre le paludisme. C’est dans les pays dont la popula-
tion exposée au risque était la plus faible que l’on a encore
observé les dépenses par habitant les plus élevées. On
constate que le financement extérieur est axé sur les activités
programmatiques, notamment la fourniture de MII et d’an-
tipaludéens, ainsi que sur les PID. Les fonds alloués par les
pouvoirs publics sont consacrés pour une plus grande part
aux ressources humaines, mais des montants importants
sont tout de même affectés aux antipaludéens et aux pulvé-
risations intradomiciliaires.
12. On observe que les pays qui se trouvent en phase de pré-
élimination ou d’élimination dépensent davantage par
personne exposée au risque que ceux qui sont en phase de
lutte. L’accroissement des dépenses s’explique en partie par
l’augmentation du financement extérieur, mais dans les pays
qui sont en phase de pré-élimination ou d’élimination, le
montant des fonds alloués par les pouvoirs publics dépasse
celui du financement extérieur.
Progrès dans la prévention du paludismeLa couverture en moustiquaires imprégnées d’insecticide s’accroît rapidement dans certains pays d’Afrique et 42 % des ménages en étaient propriétaires au milieu de l’année 2010.
13. Entre 2008 et 2010, c’est-à-dire en moins de 3 ans, 254 millions
de MII ont été fournies au total à l’Afrique sub saharienne, une
quantité suffisante pour protéger 66 % des 765 millions d’ha-
bitants exposés au risque. Il est prévu d’en fournir 35 millions
de plus avant la fin de 2010, ce qui permettra d’étendre la
protection à encore 10 % de cette population. Il faudra
néanmoins encore beaucoup d’efforts pour en doter tous les
ménages qui en ont besoin et faire en sorte que tous ceux
qui sont exposés au risque puissent dormir chaque nuit sous
une moustiquaire imprégnée.
14. Selon une estimation par modélisation, 42 % des ménages
africains étaient en possession d’au moins une MII et 35 %
des enfants de moins de 5 ans dormaient en 2010 sous une
moustiquaire imprégnée. On estime, selon ce modèle, que
dans 19 pays d’Afrique, la proportion de ménages déten-
teurs de moustiquaires a atteint ≥ 50 % en 2010.
15. Les enquêtes effectuées auprès des ménages entre 2007 et
2009 révèlent que dans 11 pays (Ethiopie, Gabon, Guinée
équatoriale, Mali, Rwanda, Sao Tomé-et-Principe, Sénégal,
Sierra Leone, Togo et Zambie) la proportion des ménages
possédant une MII avait atteint ≥ 50 %. Dans ces pays, le
pourcentage médian d’enfants de moins de 5 ans dormant
sous une moustiquaire imprégnée était de 45 %. Les faibles
taux d’utilisation relevés par certaines enquêtes s’expliquent
principalement par le nombre insuffisant de moustiquaires
pour protéger tous les membres du ménage; la proportion
de moustiquaires disponibles effectivement utilisées est très
élevée (80%).
16. C’est dans la tranche d’âge de 5 à 19 ans que la probabi-
lité d’utiliser une MII est la plus faible comparativement
aux groupes plus jeunes ou plus âgés. Chez les femmes, la
probabilité de dormir sous une moustiquaire imprégnée est
légèrement plus élevée (rapport femmes/hommes : 1,1); cela
tient en partie au fait que les femmes enceintes ont plus de
chances de dormir sous une MII que les autres femmes. Il n’y
a aucune différence dans le taux d’utilisation entre les filles et
les garçons de moins de 5 ans (rapport filles/garçons: 0,99).
17. Le nombre de personnes protégées par des PID a augmenté
en Afrique subsaharienne, passant de 13 millions en 2005 à
75 millions en 2009, ce qui signifie qu’en 2009, 10 % de la
population exposée au risque était protégée.
18. Dans les autres Régions de l’OMS, le nombre de MII livrées par
les fabricants ou distribuées par les programmes nationaux
de lutte antipaludique est plus faible qu’en Afrique (16,4
millions en 2009), mais il augmente à un rythme similaire. La
mise en œuvre des PID se maintient d’une façon générale
à son niveau historique avec 98 millions de personnes qui
étaient protégées par cette mesure en 2009 (69 millions en
Inde). A l’exception de l’Inde, le pourcentage de la popula-
tion qui bénéficie de ce genre de protection tend à être plus
faible que dans les pays d’ Afrique où ces pulvérisations sont
effectuées, peut-être en raison du caractère plus focal de la
maladie en dehors de l’Afrique.
19. Les méthodes actuelles de lutte antivectorielle dépendent
en très grande partie d’une seule classe d’insecticides, les
pyréthrinoïdes, qui sont les composés les plus couramment
utilisés pour les PID et les seuls qui servent à imprégner les
moustiquaires. En généralisant l’usage d’une seule et unique
classe d’insecticides, on accroît le risque de voir apparaître,
chez les moustiques vecteurs, une résistance qui pourrait
devenir rapidement un problème majeur de santé publique,
WORLD MALARIA REPORT 2010 xxi
notamment en Afrique, où la lutte antivectorielle au moyen
d’insecticides est actuellement menée avec des niveaux de
couverture sans précédent et où la charge de morbidité
palustre est la plus élevée.
Progrès dans la prévention du paludisme au cours de la grossesseEn ce qui concerne la couverture des femmes enceintes par le traitement préventif intermittent (TPI) on est encore loin d’avoir atteint les cibles fixées, même si quelques pays ont accompli des progrès notables.
20. Le pourcentage de femmes enceintes ayant reçu la deuxième
dose du traitement préventif intermittent allait de 2,4 % en
Angola à 62 % en Zambie selon des enquêtes auprès des
ménages effectuées dans 8 pays pour lesquels on possédait
des données relatives à la période 2007–2009. La moyenne
pondérée, qui correspond à une population de 270 millions
de personnes, est restée faible, avec une valeur de 12 %, qui
s’explique principalement par le faible taux de couverture
enregistré au Nigéria.
21. Selon les données communiquées par les programmes
nationaux de lutte antipaludique de 22 pays africains à forte
charge de morbidité palustre, le pourcentage de femmes
fréquentant les services de soins prénatals et ayant reçu la
seconde dose du TPI était de 55 % (fourchette interquartile :
47%– 61 %).
Progrès dans le diagnostic et le traitement du paludismeLe nombre de TDR et de CTA fournis est en augmentation et le pourcentage de cas suspects notifiés qui sont soumis à un examen parasitologique est passé de 67 % en 2005 dans l’ensemble du monde à 73 % en 2009. De nombreux cas sont encore traités sans diagnostic parasitologique préalable.
22. La proportion de cas suspects notifiés soumis à un examen
parasitologique a augmenté entre 2005 et 2009, notamment
dans la Région de l’Afrique (de 26 à 35 %), dans la Région de
la Méditerranée orientale (de 47 à 68 %) et dans la Région
de l’Asie du Sud-Est, Inde non comprise (de 58 à 95 %). Cette
proportion reste faible dans la plupart des pays d’Afrique:
dans 21 des 42 pays qui ont communiqué des informa-
tions sur cet examen, elle était inférieure à 20 %. D’après les
données fournies par un nombre limité de pays, il semblerait
que l’examen microscopique comme les TDR soient moins
pratiqués dans le secteur privé que dans le secteur public.
23. Dans un petit nombre de pays, comme la République démo-
cratique populaire lao et le Sénégal, on a montré qu’il était
possible d’accroître rapidement la disponibilité des tests de
diagnostic rapide à l’échelon national, en veillant à assurer
une préparation, une formation, un suivi, un encadrement et
un contrôle de qualité adéquats.
24. Le nombre de cures de CTA fournies a beaucoup augmenté,
passant de 11,2 millions en 2005 à 76 millions en 2006, pour
culminer à 158 millions en 2009. Fin 2009, 11 pays africains
fournissaient un nombre suffisant de ces cures pour traiter
plus de 100 % des cas de paludisme vus dans le secteur public
et 8 autres pays de cette région en ont délivré suffisamment
pour traiter 50 à 100 % des cas. Ces chiffres traduisent une
augmentation notable depuis 2005, où il n’y avait que 5 pays
qui fournissaient suffisamment de cures de CTA pour traiter
plus de 50 % des malades soignés dans le secteur public.
Toujours est-il que le nombre de CTA distribuées en 2009
par les programmes nationaux de lutte antipaludique dans
la Région de l’Afrique a représenté plus de cinq fois celui
des TDR fournis et 2,4 fois le nombre total de tests effectués
(examen microscopique plus TDR), ce qui indique que de
nombreux malades ont été traités par des CTA sans diagnos-
tic de confirmation.
25. En regroupant les données issues des enquêtes auprès
des ménages et celles des établissements de soins on peut
estimer, qu’en moyenne, 65 % des besoins thérapeutiques
sont satisfaits chez les malades qui fréquentent les établis-
sements de soins du secteur public. Les estimations sont
plus difficiles à établir s’agissant des malades traités dans
le secteur privé, mais les enquêtes auprès des ménages
révèlent que pour les sujets fébriles soignés dans ce secteur,
la probabilité d’être traité par un antipaludéen est de 25 %
inférieure à celle qu’ont les malades du secteur public de
recevoir un tel produit ; quant aux malades qui restent chez
eux leur probabilité de recevoir un antipaludéen est de 60 %
inférieure.
26. L’utilisation de monothérapies à base d’artémisinine compro-
met la durée de validité thérapeutique des CTA en facilitant la
propagation de la résistance à ces composés. En novembre
2010, 25 pays autorisaient encore la commercialisation
de ces monothérapies et 39 firmes pharmaceutiques les
fabriquaient. La plupart des pays qui autorisent encore la
commercialisation des monothérapies se trouvent dans la
Région de l’Afrique et la majorité des fabricants, en Inde.
27. Dans la plupart des régions du monde, la résistance des
plasmodies a rendu les anciens antipaludéens inefficaces,
mettant en péril la lutte antipaludique. Le même genre de
risque menace les antipaludéens extrêmement efficaces que
sont les dérivés de l’artémisinine et les médicaments qui leur
sont associés. La résistance de P. falciparum aux artémisini-
nes a été confirmée en 2009 à la frontière entre le Cambodge
et la Thaïlande, mais malgré l’évolution de la sensibilité des
plasmodies à ces produits, l’efficacité clinique et parasitolo-
gique des CTA n’est pas encore compromise. Depuis 2008,
on s’active à contenir la propagation des plasmodies résis-
tantes aux artémisinines.
xxii WORLD MALARIA REPORT 2010
Impact de la lutte antipaludiqueDepuis 2000, les pays sont de plus en plus nombreux à enregistrer une diminution du nombre de cas confirmés de paludisme ou du nombre d’hospitalisations et de décès notifiés. Les efforts de lutte déployés au niveau mondial ont entraîné une diminution du nombre estimatif de décès, le chiffre passant de près de 1 million en 2000, à 781 000 en 2009.
28. Dans 11 pays et 1 territoire de la Région africaine, on a enre-
gistré ces dernières années un recul de plus de 50 % des cas
confirmés ou des hospitalisations et des décès imputables
au paludisme (Afrique du Sud, Algérie, Botswana, Cap Vert,
Érythrée, Madagascar, Namibie, Rwanda, Sao Tomé-et-Prin-
cipe, Swaziland, Zambie et Zanzibar en République Unie de
Tanzanie). Dans tous ces pays, ce recul est lié à d’énergiques
interventions de lutte antipaludique.
29. En 2009, on a constaté une augmentation du nombre de cas
de paludisme dans 3 pays qui avaient auparavant fait état d’un
recul de ces cas (Rwanda, Sao Tomé-et-Principe et Zambie).
Les raisons de cette résurgence ne sont pas connues avec
certitude, mais elle souligne la fragilité des progrès réalisés
dans la lutte contre le paludisme et la nécessité de maintenir
fermement les programmes de lutte antipaludique, même
lorsque le nombre de cas a sensiblement diminué.
30. Dans les autres Régions OMS, le nombre notifié de cas
confirmés a reculé de plus de 50 % entre 2000 et 2009 dans
3 des 56 pays d’endémie palustre, et une tendance descen-
dante de l’ordre de 25 à 50 % a été observée dans 8 autres
pays. En 2009 et pour la première fois, aucun cas de paludisme
à falciparum n’a été signalé dans la Région de l’Europe. Le
recul du nombre de cas a été le moins marqué dans les pays
où les taux d’incidence étaient les plus élevés, ce qui montre
qu’il faut être plus attentif aux pays qui recèlent la majeure
partie de la charge de morbidité en dehors de l’Afrique.
31. En 2009, 8 pays se trouvaient en phase de pré-élimination
et 10 mettaient en œuvre des programmes d’élimination à
l’échelon national (8 étant entrés en phase d’élimination en
2008). Neuf autres pays (Arménie, Bahamas, Égypte, Fédéra-
tion de Russie, Jamaïque, Maroc, Oman, République arabe
syrienne et Turkménistan) ont interrompu la transmission et
s’emploient à empêcher la réintroduction du paludisme. En
2010, le Directeur général de l’OMS a certifié que le Maroc et
le Turkménistan étaient exempts de paludisme.
32. On estime que le nombre de cas de paludisme est passé de
233 millions en 2000 à 244 millions en 2005, mais qu’il est
retombé à 225 millions en 2009. Selon les estimations, le
nombre de décès des suites du paludisme est tombé de 985
000 en 2000 à 781 000 en 2009. Une diminution de la charge
de morbidité a été observée dans toutes les Régions OMS,
la baisse étant proportionnellement la plus marquée dans la
Région de l’Europe, suivie par la Région des Amériques. En
valeur absolue, c’est en Afrique que le recul le plus important
du nombre de décès a été observé.
1
WORLD MALARIA REPORT 2010 xxiii
Prefacio
Dra. Margaret Chan, Directora General de la Organización Mundial de la Salud
Los datos del Informe mundial sobre el paludismo 2010
refuerzan los argumentos para invertir en la lucha antipalúdica.
La carrera para lograr una cobertura universal con las
herramientas disponibles a día de hoy, por la que hizo un
llamamiento el Secretario General de las Naciones Unidas en
2008, continúa dando frutos. Entre 2008 y 2010 se habrán
distribuido casi 289 millones de redes mosquiteras tratadas con
insecticida en el África subsahariana, suficientes para proteger a
578 millones de personas. En África 75 millones de personas, un
10% de la población a riesgo, recibieron también protección en
2009 mediante la fumigación intradomiciliaria con insecticidas.
Estos resultados constituyen unos auténticos logros.
Estas labores de prevención están teniendo una incidencia
mesurable en la salud pública. El número anual de casos de
paludismo y muertes debidas a esta enfermedad continúa
disminuyendo, especialmente en África. El número de países
que durante la última década han conseguido reducir a la
mitad la carga del paludismo que sufrían sigue aumentando.
Por primera vez, en 2009 no se informó de ningún caso de
paludismo debido a Plasmodium falciparum en la Región de
Europa de la OMS. Uno por uno, se va reduciendo el número de
países con paludismo endémico. Este mismo año tuve el honor
de certificar que Marruecos y Turkmenistán se encuentran
libres de paludismo, y pude añadir estos países a la lista oficial
de las zonas donde se ha logrado eliminar esta enfermedad.
Están sucediendo rápidamente grandes cambios en la forma
en que nos enfrentamos al paludismo. Este es el año en que
por fin se declaró que toda persona con un presunto caso de
paludismo tiene derecho a una prueba de diagnóstico que
lo confirme. Este cambio llega más tarde de lo que debería.
Durante demasiado tiempo se ha identificado como paludismo
la fiebre en demasiados sitios. Esto se acabó. Nuestras
iniciativas de prevención han provocado cambios reales en la
transmisión del paludismo, y la mayoría de los casos de fiebre
ya no se deben a éste, incluso en África. Ello constituye otro
indicativo claro de progreso, y una señal de cómo se depuran
constantemente las estrategias de control. Disponemos de
pruebas de diagnóstico económicas, rápidas y de calidad
garantizada que pueden utilizarse en todos los niveles, incluido
el de la comunidad.
En 2009, más de una tercera parte de los presuntos casos de
paludismo notificados en África se confirmaron con una prueba
de diagnóstico, lo que representa un drástico incremento
con respecto al porcentaje inferior al 5% correspondiente
al principio de la década. Una pequeña cantidad de países
africanos han podido extender las pruebas de diagnóstico
del paludismo a nivel nacional. Ello no solo ha significado que
cada año se evite el uso innecesario de centenares de miles
de tratamientos con las terapias combinadas basadas en la
artemisinina, sino que también ha permitido implantar una
vigilancia antipalúdica precisa y puntual. Se trata de un gran
salto adelante. Solo si sabemos dónde acecha nuestro enemigo
e identificamos los lugares donde aún existe paludismo
podemos tener esperanzas de derrotarlo.
Si bien hay mucho que podemos celebrar, los datos de este
informe subrayan también la fragilidad de nuestros progresos.
Se observó un resurgimiento del paludismo en partes de
al menos tres países africanos. Se desconocen los motivos
exactos de estos fuertes incrementos, pero probablemente
reflejen alguna combinación de variación natural y fallos en las
medidas de control. Los fracasos de estos programas son un
claro recordatorio de lo que podría suceder si redujésemos la
vigilancia y no cumpliésemos nuestros compromisos colectivos.
En muchos sentidos, mantener las elevadas tasas de cobertura
con medidas de control y prevención del paludismo puede
constituir un desafío aún mayor que la propia consecución de
dicha cobertura.
No podemos dejar que este impulso se detenga. Los
significativos progresos logrados recientemente, a pesar de ser
frágiles, deben mantenerse. La comunidad internacional debe
garantizar una financiación suficiente y previsible para alcanzar
las ambiciosas metas establecidas para el control del paludismo
dentro de la carrera por cumplir los Objetivos de Desarrollo del
Milenio relacionados con la salud para 2015.
La voluntad de mantener los progresos registrados en el
terreno del paludismo no solo debe provenir de los líderes
mundiales en el ámbito de la salud y de los políticos, sino
también de las comunidades afectadas. Si estas pueden
conocer la verdadera carga del paludismo y pueden ver los
resultados de las labores de prevención y control, la voluntad
para eliminar y erradicar el paludismo nunca desaparecerá.
xxiv WORLD MALARIA REPORT 2010
Resumen
El Informe mundial sobre el paludismo 2010 amalgama la
información recibida de 106 países con paludismo endémico
con la de otras fuentes, y actualiza los análisis presentados en
el informe de 2009. También destaca la continuación de los
progresos realizados en pos del cumplimiento de los objetivos
internacionales de lucha antipalúdica a alcanzar en 2010 y 2015.
Además, el informe destaca la evolución de la financiación para
el control de la enfermedad, la forma en que estos crecientes
recursos han dado lugar a una mayor cobertura de las
intervenciones de lucha antipalúdica recomendadas por la OMS,
y la asociación entre esta rápida ampliación y las sustanciales
reducciones de la carga del paludismo.
La financiación internacional para el control de la enfermedad
ha crecido marcadamente durante la última década. Los
desembolsos alcanzaron su punto máximo histórico en 2009
con US$ 1500 millones, pero los compromisos nuevos para la
lucha antipalúdica parecen haberse estancado en 2010 en US$
1800 millones. Los países con poblaciones en riesgo de menor
tamaño continúan recibiendo más financiación por persona
a riesgo que los países más poblados. Aunque los fondos
adjudicados al paludismo son sustanciales, siguen sin alcanzar
las cifras necesarias para el control de la enfermedad, estimadas
en más de US$ 6000 millones para el año 2010.
El incremento de la financiación ha dado pie a un tremendo
progreso durante los últimos tres años en el acceso a redes
mosquiteras tratadas con insecticida. A finales de 2010 se
habrán distribuido aproximadamente 289 millones de redes
mosquiteras tratadas con insecticida en el África subsahariana,
suficientes para cubrir el 76% de los 765 millones de personas
a riesgo de contraer paludismo. Se estima que el 42% de los
hogares de África dispusieron a mediados de 2010 de al menos
una red mosquitera tratada con insecticida, y que el 35% de los
niños durmieron protegidos por uno. El porcentaje de niños que
utilizan estas redes mosquiteras continúa hallándose por debajo
de la meta del 80% fijada por la Asamblea Mundial de la Salud,
en parte porque, en algunos de los mayores países africanos, el
porcentaje de hogares provistos de al menos una red mosquitera
continuó siendo bajo hasta finales de 2009. Las bajas tasas
de uso reveladas por algunos estudios se deben a la falta de
suficientes redes mosquiteras para cubrir a todos los miembros
del hogar; los resultados de las encuestas domiciliarias sugieren
que la mayoría (el 80%) de las redes mosquiteras tratadas con
insecticida se utilizan.
Si bien la rápida ampliación de la distribución de redes
mosquiteras tratadas con insecticida en África constituye un
enorme logro de salud pública, conseguir que se mantengan los
elevados niveles de cobertura representa un formidable desafío
para el futuro. La vida útil de una red mosquitera tratada con
insecticida de larga duración se estima actualmente en tres años.
Por lo tanto, ya hay que reemplazar las redes distribuidas en 2006
y 2007, y pronto deberá hacerse lo mismo con las repartidas
entre 2008 y 2010. No sustituir estas redes mosquiteras podría
dar lugar a una resurgencia de los casos de paludismo y las
muertes debidas a esta enfermedad.
Los programas de fumigación intradomiciliaria también se
han expandido considerablemente durante los últimos años, y
el número de personas protegidas en el África subsahariana ha
pasado de 13 millones en 2005 a 75 millones en 2009, lo que
corresponde a la protección de aproximadamente el 10% de la
población a riesgo en 2009.
Los métodos actuales de control del vector del paludismo
dependen en gran medida de un único tipo de insecticidas,
los piretroides, que son los compuestos más utilizados para la
fumigación intradomiciliaria y los únicos empleados para tratar
las redes mosquiteras. El uso generalizado de un solo tipo de
insecticida incrementa el riesgo de que los mosquitos desarrollen
resistencia contra éste, lo que podría dar lugar rápidamente a
un problema de salud pública de gran envergadura. Este riesgo
resulta especialmente preocupante en África, donde se está
desplegando el control del vector mediante insecticida con
unos niveles de cobertura carentes de precedentes, y donde es
mayor la carga del paludismo.
La OMS recomienda ahora que todos los presuntos casos de
paludismo se confirmen con una prueba de diagnóstico antes
de proceder a su tratamiento. A medida que la incidencia del
paludismo disminuye en gran parte del África subsahariana,
la necesidad de diferenciar esta enfermedad de otras fiebres
no palúdicas se hace más urgente. La proporción de casos
notificados en África que han sido confirmados por una prueba
de diagnóstico ha aumentado de modo sustancial, desde menos
del 5% a principios de la década hasta aproximadamente el 35%
en 2009, pero en la mayoría de los países africanos y en una
minoría de países de otras regiones esta tasa continúa siendo
baja. Unos pocos países han mostrado que es posible ampliar
rápidamente a escala nacional la disponibilidad de pruebas
de diagnóstico para el paludismo, siempre y cuando se preste
atención a la adecuada preparación, formación, seguimiento,
supervisión y control de calidad. Dichas experiencias se han
asociado a grandes reducciones del uso de terapias combinadas
basadas en la artemisinina y a una mejor vigilancia del
paludismo.
La información facilitada por fabricantes indica que la
cantidad de terapias combinadas basadas en la artemisinina
que se han administrado ha aumentado cada año desde 2005.
A finales de 2009, 11 países africanos administraban suficientes
terapias de este tipo para cubrir más del 100% de los casos de
paludismo observados en el sector público, mientras que otros
WORLD MALARIA REPORT 2010 xxv
ocho países africanos administraron suficientes terapias para
tratar entre el 50% y el 100% de los casos. Estas cifras representan
un incremento sustancial desde 2005, cuando solamente cinco
países administraban suficientes terapias combinadas basadas
en la artemisinina para cubrir a más del 50% de los pacientes
tratados en el sector público. Sin embargo, la información sobre el
acceso al tratamiento es, en general, incompleta, especialmente
en lo referente al porcentaje de pacientes tratados en el sector
privado.
El uso de monoterapias orales basadas en la artemisinina
constituye una amenaza para la vida terapéutica de las terapias
combinadas basadas en este principio activo, ya que fomentan la
propagación de la resistencia a las artemisininas. En noviembre
de 2010, 25 países todavía permitían la comercialización de
estos productos y 39 empresas farmacéuticas continuaban
fabricándolos. La mayoría de los países que siguen permitiendo
la comercialización de monoterapias se encuentra en la región
de África, y la mayoría de los fabricantes se halla en la India.
La propagación de la resistencia a los fármacos antipalúdicos
durante las últimas décadas ha dado lugar a la intensificación
del seguimiento de la eficacia para hacer posible la detección
precoz de la resistencia. A pesar de los cambios observados en
la sensibilidad del parásito a las artemisininas, la eficacia clínica
y parasitológica de las terapias combinadas basadas en este
principio activo todavía no se ha visto comprometida, incluso en
la subregión del Gran Mekong. No obstante, ambos componentes
de la combinación farmacológica se hallan a riesgo actualmente,
y el empleo de una terapia combinada basada en la artemisinina
asociada a un medicamento ineficaz puede aumentar el riesgo
de desarrollo o propagación de la resistencia a la artemisinina.
Durante los últimos años, un total de 11 países y una zona de la
Región de África de la OMS mostraron una reducción superior al
50% de o bien los casos confirmados de paludismo o los ingresos
y defunciones por paludismo. Se detectó un descenso superior al
50% del número de casos confirmados de esta enfermedad entre
2000 y 2009 en 3 de los 56 países con paludismo endémico no
africanos, y en otros ocho países se observaron reducciones de
entre el 25% y el 50%. La Directora General de la OMS certificó
en 2010 que Marruecos y Turkmenistán habían eliminado el
paludismo. En 2009, la Región de Europa de la OMS informó por
primera vez que no se había producido ningún caso (autóctono)
de la enfermedad debido a Plasmodium falciparum.
Se estima que el número de casos de paludismo aumentó
desde 233 millones en 2000 a 244 millones en 2005, pero
descendió a 225 millones en 2009, y que el número de muertes
debidas al paludismo disminuyó desde 985000 en 2000 a
781000 en 2009. Se han observado descensos en la carga
del paludismo en todas las Regiones de la OMS; las mayores
reducciones proporcionales se han registrado en la Región de
Europa, seguida por la de las Américas. Los mayores descensos
de muertes en términos absolutos se han computado en África.
El progreso en la reducción de la carga del paludismo ha
sido destacable, pero hay pruebas de que en 2009 aumentaron
los casos de paludismo en tres países (Rwanda, Santo Tomé y
Príncipe, y Zambia). Los motivos de estas resurgencias no se
conocen con certeza. Los incrementos de casos de paludismo
ponen de relieve la fragilidad de la lucha antipalúdica y la
necesidad de mantener programas de control aun si el número
de casos se ha reducido de forma sustancial. Las experiencias de
Rwanda y Zambia indican también que el seguimiento mensual
de los datos de vigilancia de la enfermedad, tanto a nivel
nacional como subnacional, es esencial. Dado que los datos
epidemiológicos de muchos países del África subsahariana
sobre la carga y tendencias de la enfermedad siguen siendo
insuficientes, será necesario incrementar los esfuerzos para
fortalecer los sistemas de vigilancia rutinaria. Es necesario evitar
que ocurran importantes acontecimientos epidemiológicos en
países sin que éstos sean detectados e investigados.
1
xxvi WORLD MALARIA REPORT 2010
Puntos esenciales Antecedentes y contextoLos países con paludismo endémico y la comunidad mundial están ampliando las intervenciones efectivas para alcanzar los objetivos de cobertura e impacto para 2010 y el futuro.
1. En el Día Mundial de la Malaria 2008, el Secretario General
de las Naciones Unidas hizo un llamamiento para garantizar
una cobertura universal de los programas de prevención y
tratamiento del paludismo para finales de 2010.
2. El objetivo establecido por la Asamblea Mundial de la Salud
en 2005 y por la iniciativa Hacer Retroceder el Paludismo
(Roll Back Malaria, o RBM) consiste en reducir en al menos un
50% a finales de 2010 y en un 75% en 2015 las cifras de casos
de paludismo y muertes por esta enfermedad registradas en
2000.
3. En septiembre de 2008, la iniciativa RBM lanzó el Plan de
Acción Mundial sobre el Paludismo, que define las medidas
necesarias para acelerar la consecución de los objetivos
de 2010 y 2015 relativos al control y la eliminación del
paludismo.
Políticas y estrategias de lucha antipalúdicaPara cumplir las metas propuestas para 2010 y 2015, los países deben llegar a todas las personas a riesgo de contraer paludismo facilitándoles una red mosquitera tratada con insecticida o fumigación intradomiciliaria con insecticidas de acción residual, así como proporcionar pruebas de diagnóstico basadas en laboratorio para todos los presuntos casos de paludismo y un tratamiento efectivo para todos los casos confirmados.
Prevención
4. En 2009, 23 países de la Región de África y 42 de otras
Regiones de la OMS habían adoptado la recomendación de
la OMS relativa a proporcionar redes mosquiteras a todas las
personas que corriesen riesgo de contraer paludismo, y no
solo a mujeres y niños; ello representa un incremento de 13
países con respecto a 2008. Un total de 83 países, 39 de ellos
en la Región de África, distribuyen las redes mosquiteras de
forma gratuita.
5. La fumigación intradomiciliaria (IRS) con sustancias químicas
aprobadas por la OMS (incluido el DDT) sigue siendo una de
las principales intervenciones para reducir e interrumpir la
transmisión del paludismo mediante el control del vector en
todos los entornos epidemiológicos. En 2009, 71 países, 27
de ellos en la Región de África, notificaron la implantación de
IRS y 17 países informaron de que usaban DDT para dichas
fumigaciones.
6. Se recomienda el tratamiento preventivo intermitente (IPT)
para los grupos de población que viven en áreas de alta
transmisión y son especialmente vulnerables a contraer
paludismo o a sufrir sus consecuencias, en particular mujeres
embarazadas y lactantes. A finales de 2008, 35 de los 45
países del África subsahariana habían adoptado el trata-
miento preventivo intermitente para mujeres embarazadas
(IPTp) como política nacional. Papúa Nueva Guinea, en la
Región del Pacífico Occidental, adoptó también esta política
en 2009. Ningún país ha adoptado todavía una política
nacional de IPT en niños (IPTi).
Diagnóstico y tratamiento
7. Se recomienda una confirmación parasitológica rápida
mediante microscopio o con una prueba de diagnóstico
rápido (RDT) para todos los pacientes con sospecha clínica
de paludismo, antes de iniciar el tratamiento. En 2008, 33 de
los 43 países de la Región de África con paludismo endémico
y 45 de los 63 países de otras regiones declararon la reali-
zación de pruebas de confirmación parasitológica en todos
los casos presuntivos de paludismo, con independencia de
la edad del paciente, y 77 de 86 países con Plasmodium falci-
parum endémico informaron de que mantenían una política
de tratamiento combinado basado en la artemisinina para
paludismo P. falciparum.
8. Los casos confirmados de P. falciparum sin complicaciones
deben tratarse con terapia combinada basada en la artemisi-
nina. El paludismo secundario a la infección por P. vivax debe
tratarse con cloroquina allá donde este fármaco sea efectivo,
o con una terapia combinada basada en la artemisinina
apropiada en las zonas en las que P. vivax sea resistente a la
cloroquina. El tratamiento de P. vivax debe combinarse con la
administración de primaquina durante 14 días para prevenir
la recaída.
9. La OMS recomienda que las monoterapias basadas en la arte-
misinina se retiren del mercado y se reemplacen con terapias
combinadas basadas en este mismo principio activo. En
noviembre de 2010, 25 países todavía permitían la comercia-
lización de estos productos (por 37 en 2009) y 39 empresas
farmacéuticas los fabricaban. La mayoría de los países que
aún permiten la comercialización de monoterapias se halla
en la Región de África, mientras que la mayoría de los fabri-
cantes de estas medicinas se encuentra en la India.
WORLD MALARIA REPORT 2010 xxvii
Financiación de la lucha antipalúdicaLos fondos adjudicados al control de la enfermedad procedentes de fuentes internacionales aumentaron de forma consistente entre 2004 y 2009, pero se estancaron en US$ 1800 millones en 2010 y siguen siendo sustancialmente inferiores a los recursos necesarios para culminar los objetivos globales, que se estiman en un mínimo de US$ 6000 millones para el año 2010.
10. Se estima que los fondos internacionales disponibilizados
para la lucha antipalúdica han aumentado desde US$ 200
millones en 2004 a US$ 1500 millones en 2009. El gasto de los
gobiernos nacionales en el control de la enfermedad parece
haber crecido en todas las Regiones de la OMS entre 2004 y
2009; así, los grandes incrementos en financiación otorgada
por donantes no se ha debido a una reducción general del
nivel de financiación nacional, aunque los países que han
reducido su gasto recibieron más financiación externa que
los que ampliaron su gasto doméstico en el paludismo.
11. De 106 países y zonas con paludismo endémico, 77 recibie-
ron asistencia externa para control de la enfermedad entre
los años 2000 y 2008. El mayor gasto per capita continuó
produciéndose en los países con menores poblaciones en
riesgo. La financiación externa se ha concentrado en activi-
dades de programas, en particular la distribución de redes
mosquiteras tratadas con insecticida, medicamentos antipa-
lúdicos y fumigación intradomiciliaria con insecticidas resi-
duales. Se destina una mayor proporción de la financiación
de los gobiernos nacionales a los recursos humanos, aunque
se gastan sumas significativas en medicamentos antipalúdi-
cos y fumigación intradomiciliaria.
12. Los países que se encuentran en las fases de preeliminación
y de eliminación tienden a gastar más por persona a riesgo
de contraer paludismo que los países que se hallan en la fase
de control. Si bien el aumento del gasto se debe en parte a la
mayor financiación externa, la financiación gubernamental
supera a la externa en los países en fase de preeliminación y
de eliminación.
Progresos en la prevención del paludismoLa cobertura con redes mosquiteras tratadas con insecticida está creciendo rápidamente en algunos países de África; el porcentaje de hogares que poseen al menos una red mosquitera aumentó hasta el 42% a mediados de 2010.
13. En menos de tres años, entre 2008 y 2010, se distribuyó en el
África subsahariana un total de 254 millones de redes mosquit-
eras tratadas con insecticida, suficientes para cubrir al 66%
de los 765 millones de personas a riesgo. Se ha programado la
distribución de otros 35 millones de redes mosquiteras tratadas
antes de que termine 2010, suficientes para cubrir un 10% más de
la población a riesgo. No obstante, todavía es preciso un trabajo
considerable para que lleguen redes mosquiteras tratadas con
insecticida a todos los hogares que las necesitan, y para que las
personas a riesgo de contraer paludismo duerman protegidas
bajo una red todas las noches.
14. Una estimación basada en un modelo mostró que en 2010 el 42%
de los hogares africanos poseía al menos una red mosquitera
tratada con insecticida, y el 35% de los niños menores de cinco
años dormía protegido por redes mosquiteras de este tipo.
El porcentaje de hogares que disponían de al menos una red
mosquitera tratada con insecticida se estimó, en este modelo, en
≥ 50% en 19 países africanos en 2010.
15. Las encuestas domiciliarias efectuadas entre 2007 y 2009 deter-
minaron que 11 países (Guinea Ecuatorial, Etiopía, Gabón, Malí,
Rwanda, Santo Tomé y Príncipe, Senegal, Sierra Leona, Togo
y Zambia) habían alcanzado un porcentaje ≥ 50% de hogares
provistos de al menos una red mosquitera tratada con insectic-
ida. La proporción mediana de niños menores de 5 años de edad
que dormían protegidos por una red de este tipo en estos países
era del 45%. Las bajas tasas de utilización reveladas por algunos
estudios se deben principalmente a la carencia de redes mosquit-
eras suficientes para cubrir a todos los miembros del hogar; un
porcentaje muy alto (80%) de las redes mosquiteras tratados con
insecticida se utilizan.
16. Las personas de entre 5 y 19 de edad son las que menos tienden
a utilizar las redes mosquiteras tratadas con insecticida, en
comparación con las pertenecientes a los grupos de edad
superior e inferior. Las mujeres tienen una tendencia ligeramente
mayor que los hombres a dormir protegidas por una red tratada
(proporción mujeres:hombres = 1,1); ello se debe en parte a que
las mujeres embarazadas tienden más a dormir protegidas por
una red mosquitera que las demás mujeres. No existe diferencia
alguna de uso entre niños y niñas (ratio niñas:niños = 0,99).
17. El número de personas protegidas por fumigación intradomi-
ciliaria con insecticidas residuales creció en el África subsahari-
ana desde 13 millones en 2005 hasta 75 millones en 2009, una
cantidad que corresponde a una protección del 10% de la
población a riesgo en 2009.
18. En otras Regiones de la OMS, el número de redes mosquiteras
tratadas con insecticida entregadas por fabricantes o distribui-
das por programas nacionales de lucha antipalúdica es menor
que en África (16,4 millones en 2009), pero ha aumentado a un
ritmo similar. La aplicación de la fumigación intradomiciliaria
con insecticidas residuales se mantiene en general en los niveles
históricos, con 98 millones de personas protegidas en 2009 (69
millones en la India). Con la excepción de la India, el porcen-
taje de la población protegida por fumigación intradomiciliaria
tiende a ser menor que en los países africanos que emplean esta
técnica, posiblemente debido a la naturaleza más focal que tiene
la enfermedad fuera de África.
19. Los métodos actuales de lucha antipalúdica dependen sobre-
manera de una sola clase de insecticidas, los piretroides, que son
los compuestos más utilizados para la fumigación de interiores
y constituyen la única clase de insecticida utilizado para tratar
las redes mosquiteras. El uso generalizado de un solo tipo de
insecticida incrementa el riesgo de que los mosquitos desarrol-
len resistencia contra éste, lo que podría dar lugar rápidamente
a un importante problema de salud pública, especialmente en
África, donde se está desplegando el control químico del vector
con unos niveles de cobertura jamás vistos y donde es mayor la
carga del paludismo.
xxviii WORLD MALARIA REPORT 2010
Progresos en la prevención del paludismo durante el embarazoLa cobertura con tratamiento preventivo intermitente para mujeres embarazadas (IPTp) sigue hallándose lejos de los niveles fijados como objetivo, aunque algunos países han realizado un progreso notable.
20. El porcentaje de mujeres embarazadas que recibieron la segunda
dosis de IPTp osciló entre el 2,4% de Angola y el 62% de Zambia,
según las encuestas domiciliarias practicadas en ocho países
sobre los que había datos disponibles para el período 2007–2009.
La media ponderada, que representa una población de 270
millones de personas, permaneció en un nivel bajo, el 12%,
debido principalmente a las bajas tasas de cobertura en Nigeria.
21. Los datos notificados por los programas nacionales de lucha
antipalúdica de 22 países con alta carga de la Región de África
indican que el porcentaje de mujeres asistentes a centros de
atención prenatal que recibieron la segunda dosis de IPTp fue del
55% (rango intercuartil 47% – 61%).
Progresos en el diagnóstico y el tratamiento del paludismoEl número de pruebas de diagnóstico rápido y tratamientos combinados basados en la artemisinina que se administran está creciendo, y el porcentaje de casos presuntivos de paludismo que son objeto de una prueba parasitológica ha aumentado del 67% en 2005 en todo el mundo al 73% en 2009. Muchos casos todavía se tratan sin diagnóstico parasitológico.
22. El porcentaje de casos presuntivos de paludismo notificados que
son objeto de una prueba parasitológica creció entre 2005 y 2009,
en particular en la Región de África (desde el 26% hasta el 35%), la
Región del Mediterráneo Oriental (del 47% al 68%) y la Región de
Asia Sudoriental, excluyendo la India (del 58% al 95%). Las tasas
siguen siendo bajas en la mayoría de los países africanos: en 21
de los 42 países que informaron sobre las pruebas el porcentaje
de casos con confirmación parasitológica fue inferior al 20%. Los
datos de un número limitado de países sugieren que tanto la
confirmación mediante microscopía como las pruebas de diag-
nóstico rápido son menos disponibles en el sector privado que
en el público.
23. Una pequeña cantidad de países, incluyendo Senegal y República
Democrática Popular de Laos, ha demostrado que es posible
ampliar rápidamente la disponibilidad de pruebas de diagnós-
tico del paludismo a nivel nacional, siempre y cuando se preste
atención a la adecuada preparación, formación, seguimiento,
supervisión y control de calidad.
24. El número de tratamientos combinados basados en la artem-
isinina administrados experimentó un fuerte aumento desde
11,2 millones en 2005 a 76 millones en 2006, llegando a 158
millones en 2009. A finales de 2009, 11 países africanos admin-
istraban suficientes tratamientos combinados de este tipo para
cubrir más del 100% de los casos de paludismo observados
en el sector público; mientras que otros ocho países africanos
administraron suficientes tratamientos para cubrir entre un 50%
y el 100% de los casos. Estas cifras representan un incremento
sustancial desde 2005, cuando solamente cinco países admin-
istraban suficientes tratamientos para cubrir a más del 50%
de los pacientes tratados en el sector público. Sin embargo, el
número de tratamientos combinados basados en la artemisinina
distribuidos por programas nacionales de lucha antipalúdica en
la Región de África en 2009 fue más de cinco veces mayor que
el número de pruebas de diagnóstico rápido efectuadas, y 2,4
veces superior al número total de pruebas efectuadas (sumando
microscopía y pruebas diagnósticas rápidas), lo que indica que
muchos pacientes reciben tratamientos combinados basados en
la artemisinina sin diagnóstico confirmatorio.
25. Al combinar los datos de encuestas domiciliarias con los datos
provenientes de los centros sanitarios puede estimarse que, en
promedio, se cubren el 65% de las necesidades de tratamiento
de los pacientes que acuden a centros de salud públicos. Para los
pacientes tratados en el sector privado resulta más difícil realizar
estimaciones, pero las encuestas domiciliarias indican que los
pacientes con fiebre tratados en el sector privado tienen un 25%
menos de probabilidades de recibir un medicamento antipalúdi-
co que los que visitan centros del sector público, mientras que
quienes se quedan en su domicilio tienen un 60% menos de
probabilidades de recibirlo.
26. El uso de monoterapias orales basadas en la artemisinina
constituye una amenaza para la vida terapéutica de las terapias
combinadas basadas en este fármaco, ya que fomentan la propa-
gación de la resistencia a éstos. En noviembre de 2010, 25 países
todavía permitían la comercialización de estos productos y 39
empresas farmacéuticas los fabricaban. La mayoría de los países
que todavía permiten la comercialización de monoterapias se
encuentran en la Región de África, y la mayor parte de los fabri-
cantes se halla en la India.
27. La resistencia por parte del parásito ha convertido en ineficaces
otros medicamentos antipalúdicos previamente usados para el
tratamiento en la mayor parte del mundo, poniendo en peligro
el control de la enfermedad. Los derivados de la artemisinina
—que son altamente efectivos— y sus fármacos asociados son
vulnerables al mismo riesgo. La resistencia del P. falciparum a las
artemisininas quedó confirmada en la frontera entre Camboya y
Tailandia en 2009, pero, a pesar de los cambios observados en la
sensibilidad del parásito a las artemisininas, la eficacia clínica y
parasitológica de los tratamientos combinados basados en este
compuesto todavía no ha quedado comprometida. Desde 2008
se llevan a cabo actividades de contención contra los parásitos
resistentes a la artemisinina.
El impacto del control del paludismoUn número creciente de países ha registrado descensos en el número de casos confirmados de paludismo y/o ingresos y defunciones por esta enfermedad que se declararon desde 2000. Las actividades globales de lucha antipalúdica han provocado una reducción del número estimado de muertes desde casi 1 millón en 2000 hasta 784000 en 2009.
28. Un total de 11 países y una zona de la Región de África mostraron
una reducción superior al 50% en o bien los casos de paludismo
confirmados o los ingresos y defunciones por esta enferme-
WORLD MALARIA REPORT 2010 xxix
dad durante los últimos años (Argelia, Botswana, Cabo Verde,
Eritrea, Madagascar, Namibia, Ruanda, Santo Tomé y Príncipe,
Sudáfrica, Suazilandia, Zambia y Zanzíbar en la República Unida
de Tanzania). En todos los países, los descensos están asociados
a un gran despliegue de intervenciones para el control del
paludismo.
29. En 2009 se evidenció un incremento en los casos de paludismo
en tres países que previamente habían notificado reducciones
(Ruanda, Santo Tomé y Príncipe, y Zambia). Los motivos de estas
resurgencias no se conocen con certeza, pero subrayan la fragi-
lidad de los progresos en la lucha antipalúdica y la necesidad de
mantener rigurosamente los programas de control aun cuando
los casos hayan disminuido sustancialmente.
30. En otras Regiones de la OMS, el número de casos declarados de la
enfermedad descendió en más del 50% en 3 de los 56 países con
paludismo endémico entre 2000 y 2009, y se observaron tenden-
cias a la disminución de entre 25%–50% en otros ocho países. En
2009, la Región de Europa declaró por primera vez la ausencia
total de casos (autóctonos) de P. falciparum. El número de casos
disminuyó menos en los países con mayores tasas de incidencia,
lo que indica que debe prestarse mayor atención a los países que
sufren más carga del paludismo fuera de África.
31. En 2009 había ocho países en la fase de preeliminación de la
lucha antipalúdica y diez países que aplicaban programas de
eliminación de alcance nacional (ocho de los cuales entraron en
la fase de eliminación en 2008). Otros nueve países (Armenia,
las Bahamas, Egipto, Jamaica, Marruecos, Omán, la Federación
de Rusia, la República Árabe de Siria y Turkmenistán) han inter-
rumpido la transmisión y se hallan en la fase de prevención de
la reintroducción del paludismo. Marruecos y Turkmenistán
fueron certificados en 2010 como libres de la enfermedad por la
Directora General de la OMS.
32. Se estima que el número de casos de paludismo aumentó de 233
millones en 2000 a 244 millones en 2005, pero luego descendió
a 225 millones en 2009. Se estima también que el número de
muertes debidas a la enfermedad disminuyó de 985000 en 2000
a 781000 en 2009. Se han observado reducciones de la carga
del paludismo en todas las Regiones de la OMS, y los mayores
descensos proporcionales se han registrado en la Región de
Europa, seguida por la de las Américas. Las mayores disminu-
ciones de defunciones en términos absolutos se observaron en
África
1
WORLD MALARIA REPORT 2010 1
Chapter 1. Introduction
surveys provide information on the percentage of the population that
sleep under a mosquito net, and of children with fever who are treated
and the medication they receive. Information was also received from
ACT Watch on the proportion of treatment outlets that have diagnostic
facilities and antimalarial medicines in stock, and on antimalarial prices
and sales volumes. Information on malaria financing was obtained
from the OECD database on foreign aid flows and directly from the
Global Fund and US President’s Malaria Initiative (PMI).
Data were analysed and interpreted by WHO staff at headquarters
and regional offices. Numerous enquiries were also made to WHO
country offices and NMCPs to aide interpretation of country informa-
tion. Assistance in data analysis and interpretation was also provided
by ACT Watch, the Institute of Health Metrics and Evaluation (IHME),
US Centers for Disease Control and Prevention (CDC), the Global Fund,
MEASURE / DHS, and PATH. The final report was also reviewed by these
agencies.
Chapter 2 summarizes global internationally agreed goals for
malaria control and the policies and strategies recommended by WHO
to achieve them. It then discusses the indicators recommended by
WHO, and other agencies, for monitoring progress towards targets.
Chapter 3 reviews the resource requirements for meeting global
malaria control targets and recent trends in international and domestic
financing. It considers how funds allocated for malaria have been spent
and the different levels of expenditure incurred as countries move
from control to elimination.
The World Malaria Report 2010 summarizes informa-
tion received from 106 malaria-endemic countries/areas,
including 7 that are in the prevention of reintroduction
phase, and 2 countries that were certified as free of malaria
in 2010 (Morocco and Turkmenistan). It highlights progress
made in meeting the World Health Assembly (WHA) targets
for malaria control to be achieved by 2010 and 2015, and
new goals on malaria elimination set out in the Global
Malaria Action Plan (2008).
The principal data source for the World Malaria Report is national
malaria control programmes (NMCPs) in endemic countries. Standard
forms were sent to each country in the control, pre-elimination and
elimination phases (99 countries) in April 2010 (see Annex 1). The form
requested information on: (i) populations at risk, (ii) vector species,
(iii) number of cases, admissions and deaths with parasite species
breakdown, (iv) completeness of outpatient reporting, (v) policy imple-
mentation, (vi) commodities distributed and interventions undertaken,
(vii) results of household surveys, and (viii) malaria financing. Table 1.1
summarizes the percentage of countries responding by WHO Region
and month.
Information from household surveys was used to complement data
submitted by NMCPs, notably the Demographic and Health Surveys,
Multiple Indicator Cluster Surveys and Malaria Indicator Surveys. These
WHO REGION May June July August September October November Total countries
African 0% 0% 30% 88% 98% 98% 98% 43
Americas 0% 0% 81% 81% 81% 81% 90% 21
Eastern Mediterranean 0% 0% 78% 89% 89% 89% 89% 9
European 0% 100% 100% 100% 100% 100% 100% 6
South-East Asia 0% 10% 100% 100% 100% 100% 100% 10
Western Pacific 40% 100% 100% 100% 100% 100% 100% 10
TOTAL 4% 17% 64% 90% 94% 94% 96% 99
Note: Forms are expected from each country in the control, pre-elimination and elimination phases of malaria control. Forms were also received from Armenia, Russian Federation and Turkmenistan, all of which are in the prevention of reintroduction phase.
TABLE 1.1
PERCENTAGE OF FORMS RECEIVED BY MONTH BY WHO REGION, 2010
2 WORLD MALARIA REPORT 2010
Chapter 4 considers the policies that national programmes have
adopted for ITN implementation and the progress made towards
universal access to ITNs. It also reviews the adoption of policies and the
coverage achieved by IRS programmes.
Chapter 5 reports the extent to which national programmes
have adopted policies for universal diagnostic testing of suspected
malaria cases and examines trends in the availability of parasitological
testing. It then reviews the adoption of policies and implementation
of programmes for improving access to effective treatment for malaria
and to intermittent preventive treatment of malaria in pregnancy.
Finally it reviews latest trends in drug resistance, the progress made
in withdrawing oral artemisinin-based monotherapies from the
market, and efforts to contain artemisinin resistance on the Cambodia-
Thailand border.
Chapter 6 considers the type of evidence that can be used to
determine whether the burden of malaria has changed over time and
whether changes are associated with malaria control interventions. It
then summarizes the trends of malaria cases and assesses the evidence
that malaria control activities have had an impact on malaria disease
burden in each WHO Region. It concludes by presenting estimates of
the number of cases and deaths by WHO Region and worldwide for
the period 2000–2009.
Profiles of 24 countries that are showing decreases in malaria
cases, as highlighted in the main text of the report, are then presented.
Following the profiles, Annexes give data by country for the malaria-
related indicators.
In each of the following chapters, the report presents a critical
review of the evidence, and of the conclusions that can be drawn from
it. These conclusions are provided in order to stimulate improvements
in policy, financing, implementation, and monitoring and evaluation.
The purpose of the World Malaria Report is to support the develop-
ment of effective national malaria control programmes.
WORLD MALARIA REPORT 2010 3
Chapter 2. Goals, policies and strategies for malaria control and elimination
This chapter summarizes internationally agreed goals for
malaria control and the policies and strategies recom-
mended by WHO to achieve them. It has four sections:
1) goals and targets; 2) policies and strategies; 3) malaria
elimination; and 4) indicators to track progress.
2.1 Goals and targets for malaria control and elimination
The vision of the RBM Partnership is “a world free from the burden
of malaria” (1). From 2007, the United Nations (through the MDGs),
the World Health Assembly and the RBM Partnership had consistent
goals for intervention coverage and impact for 2010 and 2015 (2–4).
These goals have evolved in recent years, largely due to substantial
progress in malaria control, with goals and targets becoming increas-
ingly ambitious (Table 2.1).
In April 2008 the United Nations Secretary-General put forward
a vision of halting malaria deaths by ensuring universal coverage of
malaria interventions by the end of 2010 (5). The aim was for indoor
residual spraying (IRS) and long-lasting insecticide-treated mosquito
nets (LLINs) to be made available to all people at risk of malaria, espe-
cially women and children in Africa, and for all public health facilities
to be able to provide effective malaria diagnosis and treatment.
In September 2008 the RBM Partnership added three additional
targets as part of the Global Malaria Action Plan (6). The first is to
reduce the total number of malaria deaths worldwide to near-zero
preventable deaths by 2015. This target is more ambitious than the
previous target of a 75% reduction in the number of malaria deaths
by 2015, although there is no global consensus on how to measure
preventable deaths. The second is that malaria should be eliminated
in 8–10 countries by 2015 and afterwards in all countries that were
in the pre-elimination phase in 2008. The third goal is: “in the long
term, eradicate malaria worldwide by reducing the global incidence
to zero through progressive elimination in countries”.
Malaria control forms part of MDG 6 and is central to achieving
MDG 4, a two-thirds reduction in the mortality rate among children
under 5 years of age. Without substantial progress in controlling
malaria, which accounted for 8% of deaths < 5 globally in 2008 and
%16 of deaths < 5 in Africa (7), MDG 4 will not be achieved.
TABLE 2.1
GOALS AND TARGETS FOR MALARIA CONTROL AND THE MDGs
United Nations, the World Health Assembly and the RBM Partnership targets to 2007
RBM Partnership goals and targets from 2008
Coverage of ≥ 80% by 2010 with four key interventions:
antimalarial medicines for patients with malaria.
Achieve universal coverage for all populations at risk of malaria using locally appropriate interventions for prevention and case management by 2010.
Reduce the number of malaria cases and deaths by ≥ 50% between 2000 and 2010 and by ≥ 75% between 2000 and 2015.
By 2010, halve the 2000 malaria burden and by 2015, reduce the number of cases by three-quarters and the number of preventable deaths to near zero.
Eliminate malaria in 8 to 10 countries by 2015 and afterwards in all countries that are currently
the long-term, eradicate malaria worldwide by reducing the global incidence to zero through progressive elimination in countries.
MDG 4 target: By 2015 reduce by two-thirds the mortality rate among children under five.
MDG 6 target: By 2015 have halted and begun to reverse the incidence of malaria and other major diseases.
4 WORLD MALARIA REPORT 2010
2.2 Malaria control policies and strategies
The strategic approaches to malaria control fall into two major
areas – prevention and case management. Taken together, these
strategies work against both the transmission of the parasite from
mosquito vector to humans (and from humans to mosquitoes) and
the development of illness and severe disease in humans.
2.2.1 Malaria prevention through malaria vector control
The objectives of malaria vector control are two-fold:
reducing vector longevity, vector density and human-vector
contact; and
level, and hence the incidence and prevalence of infection and
disease.
The overarching policy and strategy for vector control is “universal
coverage with effective vector control”. The two most powerful and
most broadly applied interventions are LLINs and IRS. These inter-
ventions work by reducing the lifespan of female mosquitoes (so
that they do not survive long enough to transmit the parasite) and
by reducing human-vector contact. In some specific settings and
circumstances, these core interventions may be complemented
by other methods, such as larval source control including environ-
mental management. However, larval control is appropriate and
advisable only in a minority of settings, where mosquito breeding
sites are few, fixed and easy to identify, and to map and treat; in other
circumstances, it is very difficult to find a sufficiently high proportion
of the breeding sites within the flight range of the vector (8).
Malaria vector control, with LLIN, IRS or other interventions, is only
effective if high coverage is achieved and sustained. This requires a
sustained programme of vector control delivery operations that
are performed correctly and on time. This in turn requires special-
ized personnel at national, provincial and district levels. As well as
practical experience in the delivery of vector control interventions,
these teams must also have the capacity to monitor and investi-
gate vector-related and operational factors that may compromise
intervention effectiveness, for which specialized entomological
knowledge and skills are essential.
WHO recommendations for vector control are the following:
1. Because high coverage rates are needed to realize the full
potential of insecticide-treated nets (ITNs) and IRS, WHO recom-
mends that all people at risk in areas targeted for malaria preven-
tion should be covered with LLINs, i.e “universal coverage” (9,10).
It is currently proposed that one LLIN should be distributed for
every two persons. This approach may require refinement for
implementation at household level: for example, one option is to
distribute to each household one LLIN for every two members of
the household, rounding up in households with an odd number
of members.
2. LLINs should be either provided free of charge or highly subsi-
dized. Cost should not be a barrier to making them available to all
people at risk of malaria, especially those at greatest risk such as
young children and pregnant women (9).
3. Universal coverage with LLINs is best achieved and maintained by
a combination of delivery systems: mass distribution campaigns
can achieve rapid initial coverage, but need to be supplement-
ed by routine delivery to pregnant women through antenatal
services and to infants at immunization clinics (9).
4. In order to be protected, households must not only own LLINs but
also use them. Behaviour change interventions including informa-
tion, education, communication (IEC) campaigns and post-distri-
bution “hang-up campaigns” are strongly recommended (9).
5. Only LLINs recommended by the WHO Pesticide Evaluation
Scheme (WHOPES) should be procured by national malaria
control programmes and partners for malaria control. These nets
are designed to maintain their biological efficacy against vector
mosquitoes for at least three years in the field under recommend-
ed conditions of use, obviating the need for regular insecticide
treatment (11,12).
6. IRS consists of the application of residual insecticides to the inner
surfaces of dwellings, where many vector species of anopheline
mosquito tend to rest after taking a blood meal (10). It is effective
in rapidly controlling malaria transmission, hence in reducing the
local burden of malaria morbidity and mortality, provided that
most houses and animal shelters (e.g. > 80%) in targeted commu-
nities are treated (8). IRS is applicable in many epidemiological
settings, provided the operational and resource feasibility are
considered in policy and programming decisions. IRS requires
specialized spray equipment and techniques, and both the
machinery and the methods must be scrupulously maintained.
7. Currently 12 insecticides belonging to 4 chemical classes are
recommended by WHOPES for IRS. An insecticide for IRS is
selected in a given area on the basis of data on resistance, the
residual efficacy of the insecticide, costs, safety and the type of
surface to be sprayed. Special attention must be given to preserv-
ing susceptibility to pyrethroids, because they are the only class of
insecticides currently used on LLINs.
8. Using the same insecticide for multiple successive IRS cycles is
not recommended; instead, it is preferable to use a system of
rotation with a different insecticide class being used each year
(13). In areas where IRS is the main vector control intervention, this
rotation system may include a pyrethroid. In areas with high LLIN
coverage, pyrethroids should not be used for IRS.
9. DDT has a comparatively long residual efficacy (≥ 6 months) as
an insecticide for IRS. DDT use in agriculture is banned under the
Stockholm Convention, but countries can use DDT for IRS for as
long as necessary and in the quantities needed, provided that
the guidelines and recommendations of WHO are met and until
locally appropriate, cost-effective alternatives are available for a
sustainable transition from DDT (14).
10. The spread of insecticide resistance, especially pyrethroid resist-
ance in Africa, is a major threat, and a substantial intensification
of resistance monitoring is needed. Malaria vector bionomics
and vector distribution maps need to be updated periodically
through vector sentinel sites in different eco-epidemiological
strata to ensure that the appropriate mix of malaria vector control
interventions is being used (8).
WORLD MALARIA REPORT 2010 5
11. In most settings where IRS has been or is being deployed, ITNs
or LLINs are already in use. Neither LLINs nor IRS alone will be
sufficient to achieve and maintain interruption of transmission
in holoendemic areas of Africa or in hyperendemic areas in other
regions (9). Some observational evidence indicates that the combi-
nation of IRS and LLINs is more effective than either intervention
alone, especially if the combination helps to increase overall
coverage with vector control (15). However, using the combina-
tion should not be seen as a way of overcoming coverage gaps
due to poor operational practice: before providing people with
both IRS and LLINs, the priority should be to ensure that everyone
at risk is effectively covered by one or the other. When using the
combination of IRS and ITNs, a non-pyrethroid insecticide should
be used for IRS.
2.2.2 Diagnosis and treatment of malaria
The main objectives of an antimalarial treatment policy are:
cure of the infection and thus preventing the progression
of uncomplicated malaria to severe potentially fatal disease,
and preventing chronic infection that leads to malaria-related
anaemia;
pregnancy and its negative impact on the fetus; and
parasite reservoir of infection and infectivity.
The 2nd edition of the WHO Guidelines for the treatment of malaria
was published in March 2010 (16). The current WHO recommenda-
tions for diagnosis and treatment are as follows:
1. Prompt parasitological confirmation by microscopy or alternative-
ly by rapid diagnostic tests (RDTs) is recommended in all patients
with suspected malaria before treatment is started. Treatment
solely on the basis of clinical suspicion should only be considered
when a parasitological diagnosis is not accessible1.
2. Uncomplicated P. falciparum malaria should be treated with an
artemisinin-based combination therapy (ACT)2. A single dose of
primaquine is recommended in addition to an ACT for treatment
of P. falciparum malaria as an anti-gametocyte medicine (partic-
ularly as a component of a pre-elimination or an elimination
programme) provided the risks of haemolysis in patients with
glucose-6-phosphate dehydrogenase (G6PD) deficiency have
been considered.
3. P. vivax malaria should be treated with chloroquine in areas where
it is effective, or an appropriate ACT in areas where P. vivax resist-
ance to chloroquine has been documented. Both chloroquine and
ACTs should be combined with a 14-day course of primaquine
for the treatment of P. vivax malaria in order to prevent relapses,
subject to consideration of the risk of haemolysis in patients with
G6PD deficiency.
4. The five ACTs currently recommended for use are artemether
plus lumefantrine, artesunate plus amodiaquine, artesunate plus
mefloquine, artesunate plus sulfadoxine-pyrimethamine (SP),
and dihydroartemisinin plus piperaquine. The choice of the ACT
should be based on the efficacy of the combination in the country
or area of intended use.
5. Artemisinin and its derivatives should not be used as oral mono-
therapies for the treatment of uncomplicated malaria as this will
promote resistance to this critically important class of antimalar-
ials.
6. Severe malaria should be treated with a parenteral artemisinin
derivative or quinine, and followed by a complete course of an
effective ACT as soon as the patient can take oral medications.
When intravenous or intramuscular treatment is not feasible, e.g.
in peripheral health posts, patients should receive pre-referral
treatment with an artemisinin-based suppository and be trans-
ferred to a health facility capable of providing definitive treatment
with parenteral antimalarial medicines.
7. In settings with limited health facility access, diagnosis and
treatment should be provided at community level through a
programme of community case management (formerly known as
home-based management) of malaria.
2.2.3 Diagnosis and treatment of malaria
Intermittent preventive treatment is the administration of a full
course of an effective antimalarial treatment at specified time points
to a defined population at risk of malaria, regardless of whether they
are parasitaemic, with the objective of reducing the malaria burden
in the specific target population.
1. Intermittent preventive treatment in pregnancy (IPTp): all
pregnant women at risk of P. falciparum infection in countries
in sub-Saharan Africa with stable malaria transmission, should
receive at least two doses of sulfadoxine-pyrimethamine, given at
the first and second scheduled antenatal care visits (at least one
month apart) after “quickening” (the first noted movement of the
fetus). The doses of SP should be taken under direct observation
during the antenatal visits (17).
2. Intermittent preventive treatment in infants (IPTi): all infants at
risk of P. falciparum infection in countries in sub-Saharan Africa
with moderate to high malaria transmission should receive three
doses of SP along with the DTP2, DTP3 and measles immunization
through the routine immunization programme (18).
2.2.4 Resistance to antimalarial medicines
Antimalarial drug resistance is a major public health problem
which hinders the control of malaria. The measurement of drug
resistance in malaria is complex, as four different tools are used: (i)
therapeutic drug efficacy studies measure clinical and parasito-
logical efficacy and are the primary source to inform the treatment
policy of the national malaria control programme (NMCP); (ii) in vitro
studies measure the intrinsic sensitivity of parasites to antimalarial
drugs; (iii) molecular marker studies identify genetic mutations and
subsequently confirm the presence of mutations in blood parasites;
1. Within a short time (less than 2 hours) of the patient’s presentation at the
point of care.
2. Chloroquine remains effective against P. falciparum only in Central America;
clinical studies have confirmed 100% efficacy in Honduras and Nicaragua.
6 WORLD MALARIA REPORT 2010
and (iv) pharmacokinetic studies characterize drug absorption and
drug action in the body. While each method provides a contribu-
tion towards a more complete understanding of antimalarial drug
resistance, therapeutic efficacy studies remain the gold standard for
guiding drug policy. NMCPs should monitor the therapeutic efficacy
of antimalarial medicines over time in order to ensure early detection
of changing patterns of resistance so that national malaria treatment
policies for first- and second-line drugs can be revised and appropri-
ate management of clinical cases assured.
To interpret and compare results within and between regions and
to follow trends over time, therapeutic efficacy monitoring must be
conducted with similar standardized procedures. WHO prepared a
protocol for assessing antimalarial drug efficacy in high transmission
areas in 1996; it was updated in 2009 on the basis of expert consensus
and feedback from the field (19). WHO has also prepared a field manual
on in vitro assays for the sensitivity of malaria parasites to antimalarial
drugs (20) and a guideline on genotyping malaria parasites to distin-
guish between reinfection and recrudescence during therapeutic
efficacy testing. Parasite genotyping is now becoming increasingly
necessary due to the longer follow-up of patients (21). The following
recommendations are drawn from the 2009 edition of Methods for
surveillance of antimalarial drug efficacy:
1. National malaria control programmes should establish sentinel
sites (selected health facilities) for the surveillance of antimalarial
drug efficacy. Experience suggests that 4–8 sites per country will
achieve a balance between representativeness and practicality.
The sentinel sites should represent all the epidemiological strata
in the country but it is critical to select a “manageable” number of
sites to ensure proper monitoring and supervision.
2. Efficacy of first- and second-line medicines should be tested at
least once every 24 months at all sites. For the purposes of compa-
rability, assessments should always be conducted at the same
time of year.
3. A follow-up of 28 days is recommended as the minimum duration
for medicines with elimination half-lives of less than 7 days
(amodiaquine, artemisinin derivatives, atovaquone-proguanil,
chloroquine, lumefantrine, quinine, and sulfadoxine-pyrimeth-
amine). For medicines with longer elimination half-lives (meflo-
quine, piperaquine), longer follow-up periods are necessary.
4. The standard protocol to test the efficacy of medicines against
P. falciparum may need adjustment for P. vivax. Since P. vivax
infection relapses, many countries require primaquine therapy
for radical cure. Administration of primaquine concurrently or
soon after administration of chloroquine may conceal resistance
to chloroquine alone, resulting in underestimation of the risk of
therapeutic failure or resistance to chloroquine. Therefore, in
certain cases primaquine therapy should be postponed until after
the 28-day follow-up. Nonetheless, if local health policy includes
mandatory administration of primaquine with chloroquine, the
failure rate should be considered to be that of the combination
regimen.
5. Countries should consider changing the first-line treatment for
malaria if the total failure rate exceeds 10%; however, efficacy and
failure rates should be assessed in the context of their 95% confi-
dence intervals.
Over the last decade, most malaria-endemic countries shifted
their national treatment policies to ACTs and efficacy studies are
now conducted on combination therapies. Of particular concern is
whether there is evidence of resistance to artemisinin. Neither the
mechanism of artemisinin resistance, nor a molecular marker to
screen for it, has yet been identified. The current working definition
of artemisinin resistance is: (i) an increase in parasite clearance time,
as evidenced by ≥ 10% of cases with parasites detectable on day 3
after treatment with an ACT (suspected resistance); or (ii) treatment
failure after treatment with an oral artemisinin-based monotherapy
with adequate antimalarial blood concentration, as evidenced by the
persistence of parasites for 7 days; or (iii) the presence of parasites at
day 3 and recrudescence within 28–42 days (confirmed resistance).3
2.3 Malaria eliminationFrom a country perspective, interruption of local mosquito-
borne malaria transmission, i.e. elimination of malaria, is the ultimate
goal of malaria control. With rapid scale-up and sustained efforts,
malaria transmission can be interrupted in low-transmission settings.
However, in areas of moderate to high transmission malaria transmis-
sion can be greatly reduced, but interruption of transmission is likely
3. This definition is prone to confounding factors (known and unknown) such as splenectomy, haemoglobin abnormalities and reduced immunity.
BOX 2.1
DEFINITIONS (23,24)
Malaria control
Reducing the malaria disease burden to a level at which it is no longer a public health problem.
Malaria elimination
The interruption of local mosquito-borne malaria transmission; reduction to zero of the incidence of infection caused by human malaria parasites in a defined geographical area as a result of deliberate efforts; continued measures to prevent re-establishment of transmission are required.
Certification of malaria elimination
The official recognition of malaria-free status granted by WHO after it has been proven beyond reasonable doubt that the chain of local human malaria transmission by Anopheles mosquitoes has been fully interrupted in an entire country for at least 3 consecutive years.
Malaria eradication
Permanent reduction to zero of the worldwide incidence of infection caused by a particular malaria parasite species. Intervention measures are no longer needed once eradication has been achieved.
WORLD MALARIA REPORT 2010 7
4. These milestones should be adjusted for each country and situation, keeping in mind the resources available for notification, investigation and follow-up of malaria cases.
to require new tools. The WHO position on malaria elimination is set
out in a recent meeting report (22, 23) and is summarized below:
1. In areas of high, stable transmission, where a marked reduction
in malaria transmission has been achieved (as may be indicated
by slide positivity rates of less than 5%)4 a “consolidation period”
should be introduced, in which: (i) control achievements are
sustained, even in the face of limited disease; (ii) health services
adapt to the new clinical and epidemiological situation with a
lower case load and reduced levels of immunity; and (iii) surveil-
lance systems are strengthened to allow rapid response to new
cases. This transformation phase precedes a decision to re-orient
programmes towards elimination.
2. Countries with low, unstable transmission (as may be indicated
by less than 1 case per 1000 population per year)4 should be
encouraged to proceed to malaria elimination, with falciparum
elimination preceding vivax elimination where these species
co-exist. Before making this decision, however, they should take
account of the overall feasibility, including entomologic situation,
programmatic capacity, fiscal commitment, political commit-
ment, and potential threats to success, including the malaria
situation in neighbouring countries. Malaria elimination might
require regional initiatives and support and will require strong
political commitment.
3. Countries with an absence of locally acquired malaria cases for
three consecutive years, and the systems in place to prove this,
will be eligible to request WHO to initiate procedures to certify
that they are malaria-free.
4. Failure to sustain malaria control will result in a resurgence of
malaria, as has happened in the past, and must be avoided.
Therefore, public and government interest in intensified malaria
control and elimination needs to be sustained, even when the
malaria burden has been greatly reduced.
5. Because malaria control today relies heavily on a limited number
of tools, in particular artemisinin derivatives and pyrethroids,
which could potentially become less effective because of resist-
ance, the development of new tools for vector control and other
preventive measures, diagnosis, treatment and surveillance must
be a priority.
2.4 Indicators
The United Nations Inter-agency and Expert Group on MDG Indi-
cators has established the following specific indicators for malaria (2):
6.6 Incidence and death rates associated with malaria
6.7 Proportion of children under 5 years sleeping under insecticide-treated mosquito nets
6.8 Proportion of children under 5 years with fever who are treated with appropriate antimalarial medicines.
As policies and strategies for malaria control have evolved over
the last decade the indicators have been adapted to reflect the latest
recommendations. For example, indicator 6.7 has been expanded
to consider also the proportion of the population of all age groups
that sleep under ITNs (24). Similarly, indicator 6.8 does not yet reflect
policy recommendations to provide a parasitological test for all fever
cases.
Table 2.1 summarizes 30 indicators recommended by WHO for use
by national malaria programmes to measure coverage with malaria
control interventions (ITNs, IRS, IPTp, diagnosis and treatment) and
their epidemiological impact. The selection of indicators draws upon:
the Abuja Declaration in 2000 (3), the resolution of the World Health
Assembly in 2005 (4), the RBM Global Action Plan (6), the work of the
RBM Malaria Monitoring and Evaluation Reference Group (MERG) (25,
26), and previous editions of the World Malaria Report (24, 27). Of the
30 indicators, 20 are derived from routine information systems and
would typically be available for monitoring on a monthly basis. Not
all indicators are applicable to every epidemiological setting, hence
individual programmes would use only a sub-set of the 20 routine
indicators. The remaining 10 indicators are derived from household
surveys and, while these would not normally be available every year
for every country, they provide complementary information for
programme assessment.
The major changes from the indicator list in the World Malaria
Report 2009 are: (i) addition of indicators for low transmission settings;
(ii) addition of an indicator that considers the prevalence of parasitae-
mia in populations of children under 5 as recommended by MERG; (iii)
addition of an indicator that considers whether the number of ITNs
recorded in household surveys is sufficient to cover all household
members; (iv) addition of an indicator that considers the propor-
tion of households with at least one ITN and/or sprayed by IRS in
the last 12 months as endorsed by MERG; (v) addition of an indicator
that considers the percentage of fever cases receiving a diagnostic
test as endorsed by MERG; (vi) the case management indicator of
the proportion of fever cases receiving an appropriate antimalarial
medicine is replaced by the proportion of suspected malaria cases
receiving appropriate treatment. Appropriate treatment is defined
by national policy but will generally follow the break-down below:
Febrile children with a finger/heel stick
With positive result: received antimalarial Appropriate
With positive result: did not receive antimalarial Inappropriate
With negative result: received antimalarial Inappropriate
With negative result: did not receive antimalarial Appropriate
Febrile children not receiving finger/heel stick
Received antimalarial Appropriate
Did not receive antimalarial Inappropriate
The last change is considered necessary because WHO recom-
mends that all persons suspected to have malaria should receive a
parasitological test and because an increasing number of member
states are expanding the availability of parasitological diagnosis
through RDTs; hence it is no longer informative to determine whether
all fever cases receive an antimalarial medicine.
8 WORLD MALARIA REPORT 2010
TABLE 2.2
MALARIA INDICATORS, TARGETS AND SOURCES OF DATA
A. TRENDS IN MALARIA CASES AND DEATHS
IMPACT MEASURE INDICATOR NUMERATOR DENOMINATOR BREAK-DOWN DATA SOURCE TARGETMalaria cases 1.1 Confirmed malaria cases
(microscopy or RDT), per 1000 persons per year a
Confirmed malaria cases per year x 1000
All ages, < 5, male, female,
Routine surveillance system Reduction of cases per 1000: ≥ 50% by 2010, and ≥ 75% by 2015 in comparison with 2000
per 1000 persons per year b per year x 1000
All ages, < 5, male, female
Routine surveillance system
In low transmission / elimination settings
per year per year
Routine surveillance system
Local (introduced, indigenous, relapsing), imported, induced
Routine surveillance system
Malaria transmission1.5 Malaria test positivity ratio
malaria cases malaria cases with parasite-based test
Microscopy RDT, Pf, Pv,
Routine surveillance system
control c
In high transmission areas
1.6 Proportion of children aged 6–59 months with malaria infection
No. of children aged 6–59 months with malaria infection detected by microscopy
No. of children aged 6–59 months tested for malaria parasite by microscopy
Household survey
Malaria deaths
1000 persons per year
deaths per year (< 5 years or total) x 1000
All ages, < 5, male, female, pregnant women
Routine surveillance system Reduction in deaths per 1000: ≥ 50% by 2010 and ≥ 75% by 2015 in comparison with 2000 d,f
1.8 Malaria-specific deaths per 1000 persons per year
No. of malaria deaths per year x 1000
Population All ages, < 5, male, female, pregnant women
Verbal autopsy (surveys), complete or sample vital registration systems
In high transmission areas
1.9 All-cause < 5 mortality rate (5q0)
No. of deaths in children < 5 years from all causes x 1000
No. of children born in time period
Household surveys, complete or sample vital registration systems
No specific malaria target set
B. COVERAGE WITH INTERVENTIONS
CONTROL STRATEGY INDICATOR NUMERATOR DENOMINATOR BREAK-DOWN DATA SOURCE TARGET
Vector control
potentially covered by nets distributed e
e malaria
Routine data commodities distributed
≥ 80%
to risk groups
< 5, migrant workers
Routine data on commodities distributed
≥ 80%
2.3 Proportion of households with at least one ITN
No. of households surveyed with at least one ITN
Total No. of households surveyed
Household survey
2.4 Proportion of individuals with access to an ITN in a household f
No. of individuals with access to an ITN in a householdf
Total No. of individuals who slept in surveyed households the previous night
Household survey
2.5 Proportion of individuals who slept under an ITN the previous night
No. of individuals who slept under an ITN the previous night
Total No. of individuals who slept in surveyed households the previous night
All ages, < 5, pregnant women
Household survey ≥ 80%
malariaRoutine data from national malaria control programme contribution of
malaria control
WORLD MALARIA REPORT 2010 9
CONTROL STRATEGY INDICATOR NUMERATOR DENOMINATOR BREAK-DOWN DATA SOURCE TARGET
2.7 Households sprayed with insecticide among those targeted according to national guidelines according to national
guidelines
Routine data from national malaria control programme
100%
2.8 Proportion of households with at least one ITN and/or sprayed by IRS in the past 12 months
No. of households that have at least one ITN and/or have been sprayed by IRS in the past 12 months
Total No. of households surveyed
Household survey
Diagnosis and treatment
malaria cases that receive parasitological test g
receive parasitological testg casesRoutine surveillance ≥ 90%
2.10 Proportion of children < 5 with fever in the past 2 weeks who had a finger or heel stick
Number of children < 5 who had a fever in the previous 2 weeks who had a finger/heel stick
Total number of children < 5 who had a fever in the previous 2 weeks
P.f., P.v. probable (not tested)
Household survey
that received appropriate antimalarial treatment according to national policyh
appropriate antimalarial treatment at health facilityh
cases at health facilityP.f., P.v. not tested
Routine surveillance
special studies
100%
2.12 Appropriate antimalarial treatment of children < 5 years within 24 h of onset of feveri
No. of children < 5 receiving appropriate antimalarial treatment (according to national policy) within 24 h of onset of feveri
No. of children < 5 with fever in the past 2 weeks in surveyed households
Household survey ≥ 80%
In high transmission areas
two doses of intermittent preventive therapy
received two doses of intermittent preventive therapy
made at least one antenatal visit in 1 year
Routine data from ≥ 80%
2.14 Proportion of women who received intermittent preventive treatment for malaria during ANC visits during their last pregnancy
No. of women who received two or more doses of a recommended ACT during ANC visits to prevent malaria during their pregnancy that led to a live birth within the past 2 years
Total number of women surveyed who delivered a live baby within the past 2 years
Household survey ≥ 80%
C. MANAGEMENT SYSTEMS
SYSTEM INDICATOR NUMERATOR DENOMINATOR BREAK-DOWN DATA SOURCE TARGET
Supplies
without stock-outs of key commodities by month
stock-outs of key commodities by month
Routine reporting 100%
Reporting3.2 Annual blood examination rate
receive parasitological testRoutine surveillance
3.3 Completeness of monthly health facility reportsj each month j
reports expected each month
Commodities distributed, stock-outs, outpatient cases, inpatient cases
Routine surveillance > 90%
In low transmission / elimination settings
reporting to national malaria surveillance systemk
for malaria reporting to national malaria surveillance systemk
areas at risk for malariaRoutine surveillance system
From references 23–27. Indicators derived from household surveys are in italics.
a. Use only if > 90% of suspected cases have examination for parasites (microscopy or RDT).b. Marker for severe malaria.c. Malaria test positivity rate < 5% during the malaria season marks the readiness for transition from control stage to pre-elimination stage.d.
There is no global consensus on how to measure preventable malaria deaths.e.
indicator measures distribution and not hanging or use.f.
g.
h. P.falciparum or P. vivax cases not tested should be given an antimalarial according to national policy.
i. Comments h apply to indicator 2.12 also. The intention is to treat all persons with an appropriate antimalarial medicine; however, children are at greatest risk, especially in areas of high transmission and many
j. This indicator can vary depending on data collection forms and reporting channels. For example, the inpatient data channel may be separate from the outpatient data channel, or the commodities and disease surveil-lance data channels may be combined.
k. Facilities should report even if they have zero cases.
10 WORLD MALARIA REPORT 2010
References
1. RBM vision. Geneva, World Health Organization, 2008. http://rbm.who.int/rbmvision.html.
2. Official list of MDG indicators. New York, United Nations Inter-agency and Expert Group on MDG Indicators and United Nations Statistics Division, 2009. http://mdgs.un.org/unsd/mdg/Host.aspx?Content=Indicators/OfficialList.htm.
3. The Abuja Declaration and the plan of action. An extract from the African Summit on Roll Back Malaria, Abuja, 25 April 2000. Geneva, World Health Organization, 2000 (WHO/CDS/RBM/2000.1). http://www.rbm.who.int/docs/abuja_declaration.pdf.
4. Resolution WHA58.2. Malaria control. In: Fifty-eighth World Health Assembly, Geneva, 16–25 May 2005. Volume 1. Resolutions and decisions, and list of participants. Geneva, World Health Organization, 2005 (WHA58/2005/REC/1), 4–7. http://www.who.int/gb/ebwha/pdf_files/WHA58/WHA58_2-en.pdf.
5. Secretary-General announces ‘Roll Back Malaria Partnership’ on world malaria day. New York, United Nations Secretary-General (SG/SM/11531) 2008. http://www.un.org/News/Press/docs/2008 /sgsm11531.doc.htm
6. The global malaria action plan for a malaria free world. Geneva, World Health Organization, Roll Back Malaria, 2008. http://www.rollbackmalaria.org/gmap.
7. Black RE, et al. Child Health Epidemiology Reference Group of WHO and UNICEF (2010) Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010 Jun 5; 375(9730):1969-87. Epub 2010 May 11.
8. Malaria vector control and personal protection: report of a WHO study group, 2006. Geneva, World Health Organization. ISBN: 9241209364
9. Insecticide-treated mosquito nets: a WHO position statement. Geneva, World Health Organization, Global Malaria Programme, 2007. http://apps.who.int/malaria/docs/itn/ITNspospaperfinal.pdf
10. Indoor residual spraying—Use of indoor residual spraying for scal-ing up global malaria control and elimination. Geneva, World Health Organization, 2006. http://www.afro.who.int/index.php? option=com_docman&task=doc_download&gid=2877
11. WHO recommended insecticide products for treatment of mosquito nets for malaria vector control. WHO Pesticides Evaluation Scheme (WHOPES). Geneva, World Health Organization, 2009. http://www.who.int/whopes/Insecticides_ITN_Malaria_ok3.pdf
12. Report of the twelfth WHOPES working group meeting. Geneva, World Health Organization, 2009 (WHO/HTM/NTD/WHOWHOPES PES/20/2009.09.11). http://whqlibdoc.who.int/hq/2009/WHO_HTM_NTD_WHOPES_2009_1_eng.pdf
13. The technical basis for coordinated action against insecticide resist-ance: Preserving the effectiveness of modern malaria vector con-trol. Report of an informal consultation, May 4–6 2010, Geneva, World Health Organization. http://www.who.int/malaria/publi-cations/atoz/coordinated_action_against_irs_resistance/en/
14. The use of DDT in malaria vector control. WHO position statement. Geneva, World Health Organization, 2007. http://www.who.int/ipcs/capacity_building/who_statement.pdf
15. Kleinschmidt I et al. Combining indoor residual spraying and insecticide-treated net interventions American Journal of Tropical Medicine and Hygiene, 2009, 81:519–524.
16. Guidelines for the treatment of malaria, Second Edition 2010. Geneva, World Health Organization (WHO/HTM/MAL/2009).http://www.who.int/malar ia/publications/atoz/97892415 47925/en/index.html
17. Technical expert group meeting on intermittent preventive treat-ment in pregnancy (IPTp). Geneva, World Health Organization, 2007. http://www.who.int/malaria/publications/atoz/978924159 6640/en/index.html
18. WHO Policy recommendation on Intermittent Preventive Treatment during infancy with sulphadoxine-pyrimethamine (SP-IPTi) for Plas-modium falciparum malaria control in Africa. Geneva, World Health Organization, 2010. http://www.who.int/malaria/news/WHO_policy_recommendation_IPTi_032010.pdf
19. Methods for surveillance of antimalarial drug efficacy. Geneva, World Health Organization, 2009.
20. Methods for surveillance of antimalarial drug efficacy. Geneva, World Health Organization, 2009. http://www.who.int/malaria/resistance.
21. Basco LK. Field application of in vitro assays for the sensitivity of human malaria parasites to antimalarial drugs. Geneva, World Health Organization, 2007. http://www.who.int/malaria/resist-ance.
22. Methods and techniques for clinical trials on antimalarial drug effi-cacy: genotyping to identify parasite populations: Informal consul-tation organized by the Medicines for Malaria Venture and cospon-sored by the World Health Organization, 29–31 May 2007, Amsterdam, The Netherlands. Geneva, World Health Organization, 2008. http://www.who.int/malaria/resistance.
23. Global malaria control and elimination: report of a technical review. Geneva, World Health Organization, 2008. http://apps.who.int/malaria/docs/elimination/MalariaControlEliminationMeeting.pdf
24. Mendis K, et al. From malaria control to eradication: The WHO perspective. Tropical Medicine and International Health. 2009, 14:1-7.
25. World malaria report 2009. Geneva, World Health Organization, 2009 (WHO/HTM/GMP/2009.1).
26. Framework for monitoring progress and evaluating outcomes and impact. Geneva, World Health Organization, Roll Back Malaria, 2000.
27. Guidelines for core population-based indicators. Geneva, World Health Organization, Roll Back Malaria Partnership, 2009. http://rbm.who.int/toolbox/tool_GuidelinesForCorePopulationBased-Indicators.html.
28. World malaria report 2008. Geneva, World Health Organization, 2008 (WHO/HTM/GMP/2008.1).
29. Malaria Elimination. A field manual for low and moderate endemic countries. WHO, Geneva, 2007. http://www.who.int/malaria/docs/elimination/MalariaElimination_BD.pdf.
WORLD MALARIA REPORT 2010 11
Chapter 3. Financing malaria control
This chapter reviews the resource requirements for meeting
global malaria control targets, and recent trends in inter-
national and domestic financing. It considers how money
allocated for malaria has been spent and the different levels
of expenditure incurred as countries move from control to
elimination.
3.1 Resource requirementsGlobal resource requirements for malaria control were estimated
in the Global Malaria Action Plan to exceed US$ 5 billion a year
between 2010 and 2015 and US$ 4.75 billion between 2020 and 2025
(1)1. The amounts estimated for prevention and case management
interventions are shown in Table 3.1. The reduced amounts in later
years are primarily due to a projected reduction in need for diagnosis
and treatment as malaria becomes better controlled, as has been
observed in several low transmission countries over the past decade.
However, it is possible that future needs for diagnosis will not be
reduced substantially; in countries that currently have high rates of
malaria transmission, fever cases may still require parasitological
testing even if malaria has been well controlled, for as long as there is
a continuing risk of malaria transmission.
3.2 International financing of malaria control
3.2.1 Commitments for malaria control
Commitments represent firm obligations to provide money for
malaria control activities or purchasing commodities. A commitment
should normally be formalized in writing and backed by sufficient
funds. Commitments indicate the level of priority given to malaria
control but the amounts of money finally disbursed or spent may
differ from the amount committed because disbursements or expen-
ditures can be reduced if problems arise during programme imple-
mentation, or disbursements may be made based on performance
against agreed targets (2). In some cases a donor organization may
make a pledge, which is a non-binding announcement, to contribute
a certain amount of funds.
Information on commitments was obtained from several sources.
The Global Fund provides information on grant awards and funds
committed on its web site.2 The US President’s Malaria Initiative
(PMI) provides information on commitments in its annual report (3).
Information on commitments made by other donor organizations
was obtained from the Organisation for Economic Co-operation
and Development (OECD) which maintains a database on foreign
1. Kiszewski et al. estimated that between US$ 3.5 billion and US$ 5.6 billion would be required per year between 2006 and 2015, but used a slightly different basis for calculation, e.g. not budgeting for the use of RDTs in children under five years of age in Africa. (Kiszewski A et al. Estimated global resources needed to attain international malaria control goals. Bulletin of the World Health Organization, 2007, 85:623–630.)
2. http://www.theglobalfund.org/en/commitmentsdisbursements/
2010 2015 2020 2025Prevention
2091 1689 1807 10351883 2026 2047 1531
8 9 9 10SUB-TOTAL 3982 3724 3863 2576
Case managementRDTs 975 368 109 43ACTs 356 164 107 41Chloroquine and primaquine 5 2 1 0Management of severe malaria 23 16 9 4SUB-TOTAL 1359 550 226 87
Programme support 839 764 787 714 TOTAL 6180 5038 4876 3378
TABLE 3.1
GLOBAL RESOURCE REQUIREMENTS FOR MALARIA CONTROL estimated in the Global Malaria Action Plan (US$ million)
12 WORLD MALARIA REPORT 2010
aid flows.3 The OECD database only provides information until
2008, hence commitments – principally made by UNICEF, the World
Bank, the governments of Japan and of the United Kingdom – were
assumed to remain at 2008 levels in 2009 and 2010.
Commitments by the major external financers of malaria control
are shown in Figure 3.1. Funds have increased dramatically in the
past decade but appear to have stagnated in 2010, at US$ 1.8 billion,
principally because the lifetime budgets for approved Round 9
malaria proposals made in 2009 by the Global Fund (US$ 1.6 billion)
were lower than in Round 8 (US$ 2.9 billion). The total amount of
money approved reflects the total requested by countries in high
quality proposals; in Round 9 the size of requests (US$ 3.55 billion)
was smaller than in Round 8 (US$ 3.84 billion) while the proposal
acceptance rate on technical basis was lower in Round 9 (55%) than
Round 8 (68%). PMI commitments have grown substantially in the
last 5 years and were higher in 2010 than in 2009. Commitments by
other agencies are relatively small compared to the Global Fund and
PMI, however several national governments, and other agencies,
contribute resources to the Global Fund.
0
200
400
600
800
1000
1200
1400
1600
1800
2000
2004 2005 2006 2007 2008 2009 2010
US$
(mill
ions
)
OthersWorld BankPMIGlobal Fund
Figure 3.1 Funding commitments of the Global Fund, the US President’s Malaria Initiative, World Bank, and other agencies
Notes:
end dates and assume a constant level of commitment throughout the life of the grant. For -
ing from grant signature; the remainder of the total life time budget was allocated equally over the subsequent three years. For grants approved but not yet signed, 10% of the approved grant was also allocated to 2010 to account for commitments that may be made
calendar years proportionally according to the number of months of a financial year falling in each calendar year. Data for the World Bank and other agencies are only available up to 2008 and have been assumed to remain constant for 2009 and 2010.
3.2.2 Disbursements to malaria-endemic countries
A disbursement is the transfer of funds which places resources
at the disposal of a government or other implementing agencies.
Expenditures are the use of funds to pay for commodities, buildings,
equipment, services or salaries. Information on disbursements often
lags behind information on commitments by one year or more and
information on expenditures may be delayed for longer. This is
because of the time required to transfer money (often in instalments)
or make expenditures as well as the need to report after transac-
tions have been completed. Also auditing is often required before
official release of expenditure data. Information on disbursements
provides a more accurate picture of the amount of money going
into malaria control than information on commitments; it is typically
more complete than that on expenditures and forms the basis of
most analyses in this report.
The Global Fund,4 UNITAID, and PMI produce reports detailing
disbursements for specific grants up to 2009. Information on
disbursements from other sources was obtained from the OECD
database, which contains information for the years 2004–2008. For
these organizations levels of disbursement in 2009 were assumed to
be equal to those in 2008.
International disbursements to malaria-endemic countries have
vastly increased over the past decade with recent increases dwarfing
the total amounts allocated in earlier years (Fig. 3.2). The Global
Fund remains the single largest source of funding for malaria control
globally. While PMI and other donors contribute significant sums
through bilateral programmes, these accounted for less than 33% of
total disbursed funding in the year 2009.
OthersWorld BankPMIGlobal Fund
0
200
400
600
800
1000
1200
1400
1600
1800
2004 2005 2006 2007 2008 2009
US$
(mill
ions
)
Figure 3.2 Disbursements to malaria endemic countries, 2004–2009
3.3 Domestic financing of malaria controlCountry reports to WHO on government expenditure for malaria
control were used to estimate national government spending.
Such reports are usually restricted to malaria-specific expenditures
incurred by NMCPs for commodities, programme supervision and
management, training and behavioural change interventions.
Much of the support for malaria control activities derives from
existing health systems in countries. This is true especially for the
treatment of acute disease – where health workers, hospitals, clinics
and other infrastructure are typically provided by the national
governments or supported by non-governmental organizations.
Such financing, though an integral component of financial support
for malaria control, has not be included in this report, because
spending on health systems and personnel is difficult to attribute
specifically to malaria and data sources are fragmented. 3. http://stats.oecd.org/qwids/
4. http://www.theglobalfund.org/en/commitmentsdisbursements/
WORLD MALARIA REPORT 2010 13
3.4 Categories of expenditure by source of fundsFigure 3.4 shows how funding from different sources is spent.
National government proportions were calculated from reports on
government expenditures for 2009 submitted by NMCPs to WHO.
Only countries with reasonably complete datasets were included (32
countries for this analysis), and all countries were weighted equally.
Information on Global Fund expenditures was obtained from the
Global Fund’s enhanced financial reporting system for years 2008
and 2009, and information on PMI expenditures from country opera-
tional plans for 2010.
0% 10% 20% 30% 40% 50%
ITNs
Other vector control
Diagnosis
Treatment
Procurement and distribution
Communication and advocacy
Training
Planning, administration, overhead
Human resources
Infrastructure and equipment
Other
Share of total expenditure
20082009
0% 10% 20% 30% 40% 50%
ITNs
Other vector control
Diagnosis
Treatment
Procurement and distribution
Communication and advocacy
Training
Planning, administration, overhead
Human resources
Infrastructure and equipment
Other
Share of cumulative expenditures
0% 10% 20% 30% 40% 50%
ITNs
Other vector control
Diagnosis and treatment
Intermittent treventive treatment
Pharmaceutical management
Communication and advocacy
Capacity building
Monitoring and evaluation
Staffing and administration
Other
Share of total expenditure
CommoditiesOther
Figure 3.4 Use of funds from different sources
In addition, malaria prevention and treatment can be financed by
private “out-of-pocket” expenditures. Such funding is not considered
here because data are not readily available, although it can form a
substantial portion of the available funding for malaria control
globally. Ultimately this means that the financing situation presented
in this section is incomplete and likely to provide an underestimate
of the total financial resources available for malaria control. However,
the sources excluded here are much less likely to be affected by the
actions of countries and donors; thus there is some advantage in
focusing on traceable government malaria expenditures since they
are likely to provide the most reliable record of the levels of funding
available for malaria control and, in particular, the changes over
time.
Although information on domestic financing for malaria is incom-
plete, countries report spending on malaria control to WHO and
some analysis of recent trends in spending at the regional level
is possible. The World Malaria Report 2009 (3) examined whether
increases in external funding would lead to a reduction in domestic
financing for malaria control – domestic funding should be at least
maintained even with increased external finance in order to keep
programmes sustainable and ensure that the increased financing
from donors is additional. The evidence was mixed. A more consist-
ent picture emerges from data in 2004–2009. Domestic financing
has increased across all WHO regions (Fig. 3.3). However, when indi-
vidual countries which increased or maintained spending on malaria
relative to 2004 were compared to those with reduced spending, the
latter had received more external financing (US$ 2.93 per person at
risk per year on average) than those which increased their domestic
spending (US$ 0.69 per person at risk per year).
Africa
Americas
Eastern Mediterranean
Europe
South-East Asia
Western Pacific
0
100
200
300
400
500
600
700
800
900
2004 2005 2006 2007 2008 2009
Gove
rnm
enta
l fin
ancin
g rela
tive t
o 200
4
Figure 3.3 Trends in governmental financing for malaria controlby WHO Region
Source: missing more than 2 of 6 data points for government spending between 2004 and 2009 were excluded. Missing values were imputed based on the average of the two adjacent years if the missing data were in the middle of the range; if the data points were at the end of the range the value for the most proximate year were used. Data were indexed to the year 2004 in each country, then averaged within each year across regions.
a) Government
b) The Global Fund
c) PMI
14 WORLD MALARIA REPORT 2010
National government expenditure is generally focused on human
resources, IRS programmes and antimalarial medicines, while the
majority of Global Fund resources are used for ITNs, antimalarial
treatment and programme management. Relatively small amounts
are spent on diagnosis by the Global Fund and national govern-
ments. PMI expenditure patterns are similar to those of the Global
Fund but with more emphasis on IRS (expenditures on diagnosis are
not separated from expenditures on treatment). PMI expenditure on
ITNs, IRS, diagnosis and treatment includes expenditures associated
with programme implementation such as procurement and distribu-
tion costs as well as commodity costs. This pattern of expenditure
is consistent with the analysis presented in the World Malaria Report
2009 (4).
3.5 Disbursements by countryAs total external assistance for malaria-endemic countries has
expanded over the last decade so has the number of countries
receiving such aid. In the year 2010, 106 countries and areas are
considered to be endemic for malaria. The number of countries
receiving external assistance for malaria increased from 53 in 2004
to 77 in 2008.
There is considerable variation in the amounts of external funding
allocated to malaria-endemic countries. Larger amounts of money
per capita are allocated to countries with smaller populations at risk,
as noted in the World Malaria Report 2009. The amounts per capita
increased for countries of all sizes but the gap in funding between
smaller and more populous countries has not narrowed (Fig. 3.5).
a) WHO African Region
0
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
2004 2005 2006 2007 2008
US$
per c
apita
Large countries (>15 million)
Medium countries (5–15 million)
Small countries (<5 million)
b) Outside WHO African Region
Large countries (>15 million)
Medium countries (5–15 million)
Small countries (<5 million)
0
0.20
0.40
0.60
0.80
1.00
2004 2005 2006 2007 2008
US$
per c
apita
Figure 3.5 Disbursements per person at risk by size of the population at risk by WHO Region
3.6 Disbursements by stage of malaria controlWHO recognizes four stages in the progression of countries
towards the elimination of malaria: control, pre-elimination, elimi-
nation, and prevention of reintroduction (5). Figure 3.6 shows
international financing for countries relative to these stages for the
years 2004–2008 and government financing for 2004 per person at
risk of malaria per year. No donor disbursement data or government
financing data were available for countries in the prevention of re-
introduction stage.
0
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
Control Pre-elimination Elimination
US$
per p
erso
n
External
Domestic
Figure 3.6 Annual external and domestic financing by stage of malaria control
Source:2008) and government financing was based on country reports to the WHO (2004–2009). The sample includes 64 countries in the control stage for donor financing, 56 for govern-ment financing; for pre-elimination: 4 for donor funding and 1 for government financing;
risk was used to account for differing time periods of data from different sources.
Donor disbursements per person at risk were similar for control
and pre-elimination countries, both below US$ 1. In the elimination
phase, external funding per person at risk was higher, around US$ 4.5.
The number of countries (nine) in the elimination phase, however, is
small. Furthermore, data on donor disbursements are only available
for 5 of these countries, all of which are in the WHO European Region.
The analysis indicates that spending per person at risk may need
to be higher as countries approach the elimination of malaria. This
could be partly because the cost of programme implementation is
higher in this Region owing to differences in purchasing power and
other infrastructural differences but could also reflect the costs of
maintaining well-functioning surveillance systems.
Countries in the pre-elimination and elimination phases have
higher amounts of government spending per person at risk than
countries in the control phase, and government funding exceeds
that of external funding. This may be because countries in pre-elim-
ination and elimination stages tend to have higher gross national
incomes per capita and have more government financing available
to fund health interventions in general. It may also reflect high levels
of government commitment to attain the goal of elimination.
WORLD MALARIA REPORT 2010 15
3.7 Conclusions
External funding for malaria control. External funding has risen
steeply in the past decade. However, commitments for malaria
control appear to have stagnated in 2010 owing to smaller amounts
requested in high quality proposals and thereby approved in Round
9 of the Global Fund malaria grants in 2009 (US$ 1.6 billion) compared
to Round 8 in 2008 (US$ 2.9 billion). The reduced amount has not been
fully compensated by the increased amounts of funding provided
by the PMI. The amounts committed to malaria still fall short of the
resources required for malaria control, estimated at more than US$ 6
billion for the year 2010.
Funding by national governments. Spending on malaria control
appears to have risen in all WHO regions in the countries that
reported financial data. Large increases in donor financing therefore
do not appear to have resulted in an overall reduction in the amount
of domestic financing, although countries which had reduced their
spending had received more external financing than those which
increased their domestic spending.
Use of external and government funds. External financing appears to
be concentrated on programme activities, particularly the procure-
ment of ITNs, antimalarial medicines and IRS. A larger proportion of
national government financing is directed towards human resources
but significant amounts are also spent on antimalarial medicines and
IRS.
Funding per person by population size. International disbursements
for malaria increased between 2004 and 2008 to countries of all sizes.
However those with smaller populations at risk continued to receive
a greater amount of funding per person at risk than did the more
populous countries. Outside the African Region the gap in funding
between more populous countries and less populous countries has
widened. In the WHO African Region the amount per capita provided
to the least populous countries decreased in 2007.
Funding per person by phase of malaria control. Countries in the
pre-elimination and elimination phases appear to spend more per
person at risk of malaria than countries in the control phase. This
finding is in line with other analysis which suggests that funding
per person at risk will need to expand as countries progress towards
elimination (6). While the increased spending is partly due to larger
amounts of external financing, government financing exceeds that
of external financing in countries in the pre-elimination and elimina-
tion stages.
16 WORLD MALARIA REPORT 2010
References
1. The global malaria action plan. Geneva, World Health Organiza-tion, Roll Back Malaria, 2008. http://www.rollbackmalaria.org/gmap
2. Low-Beer D et al. Making performance based funding work for health, 2007. PLoS Medicine, 4(8): e219.
3. Sustaining momentum against malaria: saving lives in Africa. The President’s Malaria Initiative, Fourth annual report, 2010. http://www.f ightingmalar ia.gov/resources/reports/pmi_annual_report10.pdf
4. World malaria report 2009. Geneva, World Health Organization, 2009. (WHO/HTM/GMP/2009.1).
5. Mendis K, et al. From malaria control to eradication: The WHO perspective. Tropical Medicine and International Health, 2009, 14:1–7.
6. Sabot O, et al. Costs and financial feasibility of malaria elimina-tion. Lancet, 2010, 376: 1604-1615.
WORLD MALARIA REPORT 2010 17
Chapter 4. Vector control
This chapter considers the policies that national programmes
have adopted for ITN implementation and the progress
made towards universal access to ITNs. It also reviews the
adoption of policies and the coverage achieved by IRS
programmes. WHO does not collect data systematically
on other vector control interventions such as larval control
since these methods are only appropriate in a limited and
specific set of environmental conditions.
4.1 ITN policy and implementation
4.1.1 Policy adoption
Adoption and implementation of policies for ITN programmes by
WHO Region are shown in Table 4.1. Adoption of policies by country
is shown in Annex 4. In 2009, 39 of 43 malaria-endemic countries in
the WHO African Region, and 44 of 63 endemic countries in other
Regions reported having a policy of providing ITNs free of charge.
ITNs were being distributed to all age groups in 23 countries in the
African Region, which represents approximately two-thirds of the
countries responding to questions about ITN policy. The proportion
of countries providing ITNs to all age groups is higher outside the
African Region.
Several distribution channels are used in each Region. Antenatal
clinics are the most widely used channel in the African Region,
although greater amounts of ITNs are distributed through mass
campaigns. Mass campaigns are the most commonly used channel
in other WHO Regions.
4.1.2 Numbers of ITNs distributed
The Alliance for Malaria Prevention (AMP) collates information on
the number of LLINs delivered by 7 manufacturers (Sumitomo/A-Z,
Vestergaard-Frandsen, Clarke, BASF, Intection, Tana Netting, and
Yorkool) which are believed to supply almost all ITNs delivered to
countries in Africa. In Africa almost all ITNs distributed are long-last-
ing ITNs (LLINs).
The number of nets delivered by manufacturers increased from
5.6 million in 2004 to 88.5 million in 2009 in sub-Saharan Africa (from
5.4 million to 78.5 million in countries in the WHO African Region,
which does not include Djibouti, Somalia and Sudan). In the first
three quarters of 2010 a further 106 million ITNs were delivered. Thus,
in less than three years between 2008 and 2010 a cumulative total of
254 million ITNs were supplied and delivered to sub-Saharan Africa,
enough to cover 66% of the 765 million persons at risk (assuming 2
people sleeping under each ITN). It is expected that this percentage
will have increased further by the end of 2010, with an additional 35
million ITNs scheduled for delivery in 2010.
More than 50% of the ITNs delivered between 2008 and 2010 were
delivered to 7 countries: Democratic Republic of the Congo, Ethiopia,
Kenya, Nigeria, Sudan, Uganda, and United Republic of Tanzania,
which comprise 56% of the population at risk in sub-Saharan Africa
(Fig. 4.1).
POLICY AFRICAN AMERICASEASTERN
MEDITERRANEAN EUROPEANSOUTH-EAST
ASIAWESTERN PACIFIC
GRAND TOTAL
Number of endemic countries/areas* 43 23 12 8 10 10 106
ITNs distributed free of charge 39 12 9 4 10 9 83
ITNs/LLINs sold at subsidized prices 28 4 1 1 0 2 36
ITNs/LLINs distributed to all age groups 23 13 8 3 10 9 66
ITNs/LLINs distributed through mass campaigns to all age groups 26 11 4 7 7 55
ITNs/LLINs distributed through mass campaigns to < 5 only 13 2 0 1 0 16
ITNs/LLINs distributed through antenatal clinics 38 5 5 2 4 3 57
ITNs/LLINs distributed through EPI clinics 29 0 1 2 2 34
TABLE 4.1
ADOPTION OF POLICIES FOR ITN PROGRAMMES BY WHO REGION, 2009
18 WORLD MALARIA REPORT 2010
WHO receives information from NMCPs on the number of ITNs
distributed each year, which may include ITNs delivered to regional
warehouses, health facilities, and end-users. The number of nets
distributed by NMCPs each year is lower than the number delivered
by manufacturers (Fig. 4.2). The difference is at least partly due to a
time lag between the arrival of nets in a country and their distribu-
tion by the NMCP; the interval between manufacturer delivery and
NMCP distribution implied by the reported data was 5.2 months in
2008–2009, which may reflect the time required to organize and
conduct mass campaigns or to distribute nets through antenatal
clinics or other routine systems. The difference may also be partly
due to under reporting by NMCPs.
For countries in other WHO Regions, information from manu-
facturers is less complete and not available before 2009, but 9.9
million ITNs were reported as delivered in 2009 and 16 million ITNs
in the first three quarters of 2010. The largest numbers of ITNs were
delivered to Indonesia (3.4 million), India (2.9 million), Papua New
Guinea (2.2 million), Afghanistan (2.0 million), United Arab Emirates
(1.9 million) and Pakistan (1.5 million). United Arab Emirates hosts a
United Nations Humanitarian Response Depot hub and ITNs stored
there will ultimately be transported for use in emergency situations
in the region.
The number of ITNs distributed by NMCPs has risen steadily since
2000 (Fig. 4.3), even though some nets distributed by NMCPs in
countries outside Africa do not appear to be captured by the AMP
recording system, possibly because they are manufactured locally.
The countries distributing most ITNs between 2007 and 2009
were India (17.2 million), China (2.8 million), Indonesia (2.3 million),
Myanmar (2.3 million), Bangladesh (2.1 million), Afghanistan (1.6
million), and Cambodia (1.6 million).
4.1.3 Coverage achieved at national level
Household surveys are the preferred means of assessing whether
or not sufficient ITNs have been delivered to cover populations at risk
of malaria, although surveys are not conducted frequently enough
to provide up-to-date estimates for most countries. Nationally repre-
Figure 4.1 Number of ITNs delivered by manufacturers to countries in sub-Saharan Africa, 2000–2009
Figure 4.2 Cumulative number of ITNs distributed in sub-Saharan Africa, 2000–2009
Figure 4.3 Number of ITNs distributed by NMCPs by WHO Region, 2000-2009
Figure 4.4 Trends in percentage of children sleeping under an ITN for countries with more than one survey, 2000–2009
0
20
40
60
80
100
120
2004 2005 2006 2007 2008 2009 2010
Num
ber o
f ITN
s (in
milli
ons)
Other countriesUgandaKenyaUR TanzaniaSudanEthiopiaDR CongoNigeria
0
50
100
150
200
250
300
350
2004 2005 2006 2007 2008 2009
Num
ber o
f ITN
s (in
millio
ns)
Manufactuer deliveries
NMCP distribution
10
100
1000
10 000
100 000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Num
ber o
f ITN
s (in
thou
sand
s)
Africa
Americas
Eastern Mediterranean
EuropeSouth-East Asia
Western Pacific
0
10
20
30
40
50
60
Swazi
land, 2
000,2
007
Côte d'I
voire,
2000
,2006
Nigeria
, 200
3,200
8
DR Congo, 2
001,2
007
Niger, 2
000,0
6
Burundi
, 200
0,200
5
Uganda,
2000
,09
Burkina
Faso,
2003
,2006
Camero
on, 20
00,20
06
Central
Africa
n Rep.
, 200
0,200
6
Benin, 2
001,2
006
Mozambiq
ue, 20
07,20
08
Malawi, 2
000,0
6
UR Tanza
nia, 2
099,2
008
Sierra
Leone
, 200
0,200
8
Ghana, 2
003,2
008
Senega
l, 200
0,200
9
Ethiop
ia, 20
05,20
07
Togo, 2
000,2
006
Guinea-
Bissau,
2000
,2006
Zambia
, 209
9,200
8
Madagas
car, 2
000,2
009
Kenya,
2000
,2009
Gambia
, 200
0,200
6
Rwanda, 2
000,2
008
Sao To
me and
Princi
pe, 20
00,20
09
Child
ren
sleep
ing u
nder
an
ITN
the p
revi
ous n
ight (
%)
IncreaseFirst survey
WORLD MALARIA REPORT 2010 19
sentative household survey information for 2007–2009 is shown in
Table 4.2. The surveys cover 21 countries in the WHO African Region
representing 59% of the population at risk. National surveys are not
undertaken as frequently outside Africa due to the more focalized
distribution of malaria in other parts of the world.
The weighted average of households owning an ITN within the
African countries surveyed was 28%, while 20% of children < 5 years
slept under an ITN the previous night. This weighted average is lower
than might be expected because the most recent surveys for the
Democratic Republic of the Congo and Nigeria, the most populous
countries on this list, do not yet cover the period following large mass-
distribution campaigns. In addition the proportion of the population
sleeping under an ITN may be lower because many estimates are
Figure 4.5 Trends in estimated ITN coverage, sub-Saharan Africa 2000–2009
05
1015202530354045
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
ITN co
vera
ge (%
)
% households owning at least one ITN
% children <5 sleeping under an ITN
REGION / COUNTRY
% households with at least
one ITN
% of population potentially covered by available ITNs
% of population sleeping under
an ITN
% <5 sleeping under
an ITN
% of pregnant women sleeping
under an ITNType
of survey
AFRICAN REGIONAngola, 2006–2007 28 15 12 17 22DR Congo, 2007 9 4 5 6 7Equatrial Guinea, 2008 64Ghana, 2008 33 24 17 28 20Gabon, 2008 70 55Kenya, 2008–2009 56 50 36 46 48Liberia, 2009 47 26 22 26 32Madagascar, 2008–2009 57 36 37 45 46Mali, 2008 82 79Mozambique, 2007 16 7
22 15 6 10 98 5 4 5 5
Rwanda, 2007–2008 57 41 41 56 6078 5466 40 28 29 2959 564 2 0 1 1
Togo, 2008 55 35 MOH-CDCUganda, 2009 47 32 33 77UR Tanzania, 2008 39 25Zambia, 2008 62 41 43Weighted average 28 13 9 19 12SOUTH-EAST ASIAN REGION
3 2 2 4 3
taken from household surveys (DHS) which are normally carried out
during the dry season when malaria transmission is not at its most
intense. For those countries with more than one household survey,
the results indicate increasing rates of coverage (Fig. 4.4).
In the absence of a recent household survey, it is possible to estimate
ITN coverage by combining data from manufacturer reports on ITNs
delivered to countries, NMCP reports on ITNs distributed within
countries, and previous household surveys as described in the World
Malaria Report 2009 and by Flaxman et al. (1). The advantage of such
an approach is that it uses all available data to estimate ITN coverage
for years in which there has been no survey.
The percentage of households owning an ITN, and children sleeping
under an ITN, for 44 sub-Saharan African countries are shown in
Table 4.3. The estimates are for 30 June of each year, including 2010.
The estimate for 2010 assumes that all nets delivered by manufactur-
ers by June 2010 have been distributed by NMCPs (the average lag
between manufacturer delivery and distribution by MoHs estimated
to be 5.2 months as noted above). Overall, 41% of households were
estimated to have owned an ITN in 2009, rising to 42% in 2010, repre-
senting a substantial increase from the 27% estimated in 2007. In 19
countries the proportion of households owning an ITN was estimated
to have reached more than 50% in 2010. The proportion of children
sleeping under a net in 2010 was estimated to be 35%, compared to
17% in 2007 (Fig. 4.5).
The results of the model are sensitive to the assumptions regarding
the lifespan (decay of efficacy) of nets. The model assumes that on
TABLE 4.2
ITN COVERAGE FROM NATIONALLY REPRESENTATIVE HOUSEHOLD SURVEYS, 2007–2009
20 WORLD MALARIA REPORT 2010
COUNTRY
% of population
at risk
% of households owning at least one ITN Uncertainy bounds 2010
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Lower UpperAngola 100% 5 7 7 6 5 6 14 20 21 22 23 11 45 Benin 100% 3 4 5 6 9 15 30 42 57 61 55 34 83 Botswana 65% 2 2 2 3 4 8 20 34 31 26 35 18 58 Burkina Faso 100% 2 3 5 8 10 14 22 27 35 55 49 41 64 Burundi 78% 6 6 6 6 9 12 18 21 23 27 31 17 64 Cameroon 100% 4 4 4 5 6 12 24 20 15 19 28 15 42 Central African Rep. 100% 4 4 4 5 6 10 15 20 26 26 21 13 36 Chad 99% 6 6 5 5 4 4 5 7 8 9 10 5 20 Comoros 100% 17 17 12 13 12 12 12 12 11 14 20 11 37 Congo 100% 1 1 2 2 3 6 7 8 8 8 9 4 23 Côte d’Ivoire 100% 3 3 3 3 3 2 5 9 9 9 11 5 26 DR Congo 100% 2 3 3 3 3 4 7 12 29 53 54 46 78 Djibouti 50% 2 2 3 3 4 6 10 36 80 82 64 46 120 Equatorial Guinea 100% 2 2 2 2 3 4 6 29 63 47 31 20 48 Eritrea 100% 26 45 64 78 78 75 71 67 71 59 69 56 79 Ethiopia 67% 0 1 1 2 2 5 22 57 99 91 72 48 100 Gabon 100% 1 1 2 2 3 5 13 38 70 66 54 39 73 Gambia 100% 26 25 23 23 24 36 43 35 39 49 57 32 77 Ghana 100% 2 2 2 4 6 10 16 27 38 47 47 37 69 Guinea 100% 1 1 1 1 1 1 3 5 8 10 10 5 22 Guinea-Bissau 100% 15 15 14 14 15 34 47 38 35 41 52 28 70 Kenya 76% 10 11 11 12 15 24 51 63 59 70 71 57 101 Liberia 100% 1 1 2 2 3 6 27 53 51 44 46 30 70 Madagascar 100% 3 3 3 3 5 29 58 67 66 57 51 39 70 Malawi 100% 2 3 8 23 31 30 38 34 29 38 51 29 71 Mali 100% 2 2 3 4 7 18 41 68 82 87 90 67 96 Mauritania 90% 1 1 1 1 2 3 5 8 9 8 9 4 17 Mozambique 100% 2 3 4 6 8 8 9 15 26 36 42 31 62 Namibia 72% 1 2 2 2 3 4 12 25 31 29 29 15 61 Niger 100% 7 7 8 10 14 33 59 58 49 63 61 56 74 Nigeria 100% 1 1 1 1 1 1 2 5 10 14 15 11 26 Rwanda 100% 2 2 3 4 7 17 41 52 56 58 58 33 83 Sao Tome and Principe 100% 33 34 27 27 26 19 36 77 76 64 82 63 93 Senegal 100% 7 8 9 11 16 20 29 33 42 50 57 24 89 Sierra Leone 100% 4 4 4 4 3 5 9 20 33 38 40 27 63 Somalia 100% 0 1 1 1 1 2 9 14 15 15 16 7 34 South Africa 10% 7 10 11 12 12 11 9 10 10 10 20 10 30 Sudan 100% 1 1 2 2 3 8 19 21 16 19 23 13 47 Swaziland 28% 2 3 4 5 5 7 12 14 18 21 25 14 57 Togo 100% 5 6 9 16 51 65 43 45 56 71 65 56 80 Uganda 100% 2 2 2 2 3 6 17 24 32 49 46 39 67 UR Tanzania 100% 2 2 3 7 16 19 26 38 37 45 72 66 75 Zambia 100% 6 9 12 13 16 29 45 54 65 77 84 65 92 Zimbabwe 50% 2 2 3 3 4 9 17 32 56 54 44 24 86 Sub-Saharan Africa 95% 3 3 4 5 7 11 19 27 34 41 42 Uncertainty bounds Lower 2 3 3 4 6 10 17 25 32 38 38
Upper 3 4 4 6 8 12 21 29 36 43 46
Note: Estimates were derived from the model of Flaxman et al.
survey are available for a particular year then household survey results and model results should be very similar, differing only if the survey was undertaken at a different
for some countries coverage rates may therefore be higher than household survey results which are calculated for the total population, both at risk and not at risk. As three countries (Burundi, Central African Republic and Mozambique) did not have sufficient survey information in 2000–2006, prior assumptions were used to estimate coverage.
TABLE 4.3
ESTIMATES OF THE PROPORTION OF HOUSEHOLDS OWNING AT LEAST ONE ITN, SUB-SAHARAN AFRICA, 2000–2009
WORLD MALARIA REPORT 2010 21
BOX 4.1
IMPACT OF DIFFERENT ASSUMPTIONS REGARDING DECAY OF ITN EFFICACY OVER TIME
ITN coverage is best estimated by a household survey in which respondents are asked about the mosquito nets they own and whether or not they slept under a net. Household surveys can only be undertaken every 3 to 5 years so the results available for any one country can be several years old. For that reason attempts have been made to estimate ITN coverage from the number of nets distributed by malaria control programmes using the formula below:
% of people potentially covered by ITNs =
number of ITNs distributed in the past 3 years x 2 population at risk
This formula assumes that an ITN lasts for 3 years and that on average 2 people sleep under each net. It has the advantage that it takes into account the latest efforts of malaria control programmes to distribute nets and can therefore provide up-to-date information on their progress. A drawback is that the formula assumes that the efficacy of a net remains at 100% of its maximal value for 3 years, after which it abruptly drops to zero. Such a decay function, while computationally convenient, is unrealistic; efficacy (and retention) of nets is likely to decrease gradually, starting from the first day after distribution. Two other possible decay functions, each with an average lifespan for a net of 3 years (with a maximum life of 5 years), are represented in the figure below.
The way that the efficacy of a net is assumed to decay will not affect population estimates of coverage if a constant number of nets are distributed each year (since the average lifespan is the same). However, if programmes are expanding, the assumption that a net retains 100% efficacy for 3 years will produce slightly higher estimates of ITN coverage than would models using other decay functions. Conversely, if programmes are contracting, the assumption that a net retains 100% efficacy for 3 years will produce lower estimates of ITN coverage because other methods assume that nets distributed more than 3 years earlier continue to be effective.
BOX 4.2
BOTTLENECKS IN ACHIEVING UNIVERSAL ITN COVERAGE
Household surveys enable a number of indicators to be calculated in order to assess ITN coverage. The figure below shows several indicators calculated from the MIS in Liberia 2009 and from the DHS in Kenya 2008. By looking at indicators in combination it is possible to see where bottlenecks in achieving effective coverage are located (2).
In Liberia, 47% of households own at least one ITN. The ITNs available in households could potentially cover 26% of the population at a ratio of two people sleeping under each net. The proportion of people actually sleeping under an ITN is 22% suggesting that a high proportion of available nets are used. Only 5% of the population lives in households with enough ITNs to cover all occupants, but in such households everyone does sleep under a net. Thus it appears that in Liberia, where ITNs are provided they are in fact used. The bottlenecks are in reaching all households with an ITN (63% of households do not have any nets) and in providing enough nets for all household occupants.
In Kenya, 56% of households own at least one ITN. The ITNs available in households could potentially cover 50% of the population at a ratio of two people sleeping under each net. The proportion of people actually sleeping under an ITN is 36% suggesting that a lower fraction of available nets are used than in Liberia. About 20% of the population lives in households with enough ITNs to cover all occupants and in such households almost everyone does sleep under a net.
As in Liberia, a large proportion (45%) of Kenyan households did not own a single ITN in 2008. Hence it appears that the first priority would be to assure sufficient numbers of nets so that they are available for use; however, although usage rates are high, further benefit could be gained by increasing the regular use of existing ITNs.
Figure Box 4.1 Different models for decay in efficacy of ITNs
Figure Box 4.2 ITN coverage in Kenya and Liberia, 2008
0
20
40
60
80
100
120
0 1 2 3 4 5 6Age of ITN (in years)
Effic
acy c
ompa
red
to in
itial
valu
e (in
%) 100% efficacy 3 years
Linear decay
Exponential Kenya
Liberia
Coverage (%)0 20 40 60 80 100
households with at leastone ITN
population potentiallycovered by available nets
population sleepingunder an ITN
population living in householdswith enough ITNs for all occupants
population living in household inwhich everyone sleeps under an ITN
22 WORLD MALARIA REPORT 2010
y = 0.79 x – 0.19
R2 = 0.9110
0
20
30
40
50
10 20 30 40 50 60% of population potentially covered by available nets
% o
f pop
ulatio
n sl
eepin
g und
er a
n ITN
a) All households a) All ages
b) Households with enough ITNs to cover all occupants
b) Under 5 years old
Figure 4.6 Relationship between proportion of population sleeping under an ITN and the proportion with access to an ITN
Figure 4.8 Differences in ITN use by sex
Figure 4.7 Differences in ITN use by age group
y = 0.98 x – 0.09
R2 = 0.85
0
10
20
30
5 10 15 20 25 30% of population potentially covered by available nets
% of
pop
ulat
ion sl
eepin
g und
er a
n ITN
y = 1.4976 x – 0.0575
R2 = 0.9849
y = 1.11 x + 0.24
R2 = 0.99
0
10
20
30
40
50
60
70
0 5 10 15 20 25 30 35 40 45% of men sleeping under an ITN
% of
wom
en sl
eepin
g und
er a
n ITN
All women
Pregnant women
y = 0.99 x + 0.09
R2 = 0.99
0
10
20
30
40
50
60
0 10 20 30 40 50 60% of boys sleeping under an ITN
% o
f girl
s slee
ping
und
er a
n IT
N
1. This is examined by calculating the indicator: % of population potentially covered by available ITNs. This is: (Number of ITNs in households x 2) ÷ (Popula-tion in households), with analysis conducted at household level to determine what number of people within each household can be protected by the nets available to a household assuming that two people can sleep under each ITN.
0%
5%
10%
15%
20%
25%
30%
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+Age group (years)
Prop
ortio
n of
pop
ulat
ion sl
eepi
ng u
nder
ITN
Benin
DR Congo
Congo
Côte d'IvoireCameroon
Ethiopia
Guinea
GuyanaHaiti
Cambodia
Mali
Malawi
Niger
Pakistan
Rwanda
Senegal
Senegal
Swaziland
Chad
UR Tanzania
Uganda
Zimbabwe
average 4% of nets are discarded each year and that LLINs have a
lifespan of exactly 36 months during which they retain full efficacy.
The estimated lifespan of 3 years is based on the WHOPES testing
process, which checks that a product retains a minimum standard of
insecticidal activity for this period. However, the decay may be more
gradual and continuous than previously thought, and also vary from
place to place (Box 4.1). More attention is now being paid to monitor-
ing LLIN durability in a variety of settings, and standardized methods
are being developed. More detailed information on observed LLIN
loss rates, and how these vary with net age and between locations,
will enable the development of more realistic models for estimating
coverage and for planning replacement needs.
4.1.4 Coverage and use of ITNs at population level
With the gains in malaria control over the past decade, programmes
have advanced from providing ITN coverage only for the popula-
tions at greatest risk (children < 5 years of age, pregnant women,
and other vulnerable groups) to seeking coverage for all persons at
risk in the population. To meet this target several intermediate steps
need to be accomplished: (i) ITN programmes need to have sufficient
geographical reach to provide ITNs to all households; (ii) sufficient
nets need to be provided to households to cover all people living in
them1, and (iii) people within households need to use the available
nets. It is informative to examine to what extent the different steps
WORLD MALARIA REPORT 2010 23
are achieved in a particular country and identify where bottlenecks
may occur (Box 4.2).
In reviewing household surveys that provide the most recent
results available on ITN coverage for 27 malaria-endemic countries
between 2003 and 2009, it was evident that relatively low propor-
tions of households own an ITN (median 16%, lower quartile 5%,
upper quartile 45%); only 7 surveys were conducted during the
massive expansion of ITN programmes from 2008 to 2010. However,
within all surveys, a high proportion of available nets appear to be
used (approximately 80%) assuming that one net can cover two
people (Fig. 4.6a). Some countries such as Madagascar (2008) and
Rwanda (2008) have higher rates of use than others. These results
are consistent with previous analyses which suggest that the main
constraint to enabling persons at risk of malaria to sleep under an ITN
is lack of availability of nets (3).
Relatively few people live in households with enough nets to cover
all occupants (median of surveys in 2003–2009: 2%, lower quartile
1%, upper quartile 7%). However, in such households, the proportion
of people sleeping under a net is close to the proportion of house-
holds with enough nets to cover all occupants (Fig. 4.6b). The high
correlation between availability and use of nets could be because
households with enough nets to cover all members were motivated
to acquire sufficient nets and are therefore more likely to use them. In
some cases the percentage of people living in households in which
all members sleep under a net exceeds the percentage of house-
holds with enough nets to cover all occupants. Evidently in some
households more than two people are sleeping under one net.
A consistent pattern emerges across countries showing that
persons aged 5–19 years are least likely to use an ITN compared to
those in the younger and older age groups (Fig. 4.7). This age distri-
bution in use of nets is of concern since persons aged 5–19 are at
significant risk of malaria, especially in settings where prevention
and control efforts have shifted the malaria burden from very young
children to the older age groups.
Across all age groups, women are slightly more likely to sleep
under an ITN than men (Fig. 4.8a). The average ratio of women to
men sleeping under a net is 1.1 to 1. This is partly because pregnant
women are more likely to sleep under an ITN than other women
(ratio pregnant women: men = 1.5). There is no difference in usage
rates between female and male children < 5 years of age (Fig. 4.8b)
(ratio girls:boys = 0.99).
4.2 IRS policy and implementation
4.2.1 Policy adoption
Adoption and implementation of policies for IRS programmes by
WHO Region are shown in Table 4.4. Adoption of policies by country
is shown in Annex 4.
IRS is recommended for the control of malaria by 71 countries,
32 of which are in Africa. It is the primary vector control interven-
tion in Botswana, Mozambique, Namibia, South Africa, Swaziland
and Zimbabwe. IRS is sometimes used for control of epidemics or in
combination with ITNs in Africa. DDT is reported to be used for IRS
in 16 countries, of which 13 are in Africa. The majority of countries
report that they are undertaking insecticide resistance monitoring.
4.2.2 Coverage achieved
A total of 168 million people were protected by IRS in 2009 repre-
senting 5% of the global population at risk. The use of IRS for vector
control has increased since 2002, particularly in the WHO African
Region where 73 million people were protected in 2009 (Fig. 4.9).
About 10% of the total population at risk in the African Region were
protected by IRS in 2009, with rates exceeding 10% in Sao Tome and
Principe (83%), South Africa (80%), Equatorial Guinea (79%), Ethiopia
(50%), Gambia (47%), Zambia (43%), Zimbabwe (41%), Mozambique
(36%), Madagascar (34%), Namibia (31%), Botswana (18%) and Rwanda
(14%). IRS coverage in some African countries, including some highly
endemic African countries, exceeds that in many countries outside
Africa.
POLICY AFRICAN AMERICASEASTERN
MEDITERRANEAN EUROPEANSOUTH-EAST
ASIAWESTERN PACIFIC
GRAND TOTAL
Number of endemic countries/areas 43 23 12 8 10 10 106
IRS is recommended by malaria control programme 32 14 4 7 8 6 71
IRS is used for prevention and control of epidemics 24 8 7 7 10 7 63
IRS and ITNs used together for malaria control in at least some areas 29 10 4 6 8 6 63
DDT is used for IRS 13 3 16
Insecticide resistance monitoring is undertaken 35 12 6 5 10 6 74
Figure 4.9 Proportion of population at risk protected by IRS
0
2
4
6
8
10
12
2002 2003 2004 2005 2006 2007 2008 2009Prop
ortion
of p
opula
tion
at ri
sk p
rotec
ted
(%)
Africa
AmericasEastern MediterraneanSouth-East AsiaSouth-East Asia excl. IndiaWestern Pacific
TABLE 4.4
ADOPTION OF POLICIES FOR IRS PROGRAMMES BY WHO REGION, 2009
24 WORLD MALARIA REPORT 2010
In other WHO Regions, IRS coverage exceeded 10% of the population
at risk in only 10 countries or territories: Georgia (>100%), Kyrgyzstan
(>100%), Turkey (>100%), Azerbaijan (60%), Malaysia (36%), Solomon
Islands (32%), Belize (28%), Bhutan (27%), French Guiana (17%), and
Saudi Arabia (17%). In some settings the low coverage is explained
by the lower incidence of malaria and its more focal distribution,
so that intensive vector control is not widely applied. While some
countries have shown an increase in the proportion of the popula-
tion protected by IRS, the rate of expansion has not been nearly as
great as in many African countries.
4.3 Conclusions
Increasing access to ITNs. There has been tremendous progress
in increasing access to ITNs in the past 3 years, with more than
254 million ITNs delivered by manufacturers to countries in Africa
between 2008 and the third quarter of 2010. Model-based estimates
suggest that there has also been a substantial increase in the percent-
age of households owning at least one ITN from 27% in 2007 to 42%
in 2010.
Overall 35% of young children slept under an ITN in 2010. Low
rates of use reported in some surveys are primarily due to a lack of
sufficient nets to cover all household members; household survey
results suggest that a very high proportion (80%) of available ITNs
are used. Women are slightly more likely to sleep under an ITN than
men (ratio women:men = 1.1) this is partly because pregnant women
are more likely to sleep under an ITN than other women. There is no
difference in usage rates between female and male children < 5 years
of age (ratio girls:boys = 0.99).
The percentage of children using ITNs is still below the WHA
target of 80% partly because up to the end of 2009, ITN ownership
remained low in some of the largest African countries. Resources for
further scale-up have subsequently been made available with more
than 100 million ITNs delivered in the first three quarters of 2010,
including 52 million to the three most populous countries in Africa
(Democratic Republic of the Congo, Ethiopia and Nigeria).
Sustainability of ITN implementation. While the rapid scale up of ITN
distribution in Africa is an enormous public health achievement, it
also represents a formidable challenge for the future in ensuring that
the high levels of coverage are maintained. Much of the progress to
date has been achieved through mass campaigns and implementa-
tion through routine systems such as antenatal care and immuniza-
tion programmes. Programmes need to be in place to ensure that
those not benefiting from the campaigns also have access to nets.
Moreover, strategies need to be developed to replace the large
number of ITNs that have recently been delivered. There is uncer-
tainty over the extent to which ITN effectiveness decays over time,
but the lifespan of an LLIN is currently estimated to be 3 years. Nets
delivered in 2006 and 2007 are therefore due for replacement, and
those delivered between 2008 and 2010 soon will be. Failure to
replace these nets will increase the risk of a resurgence of malaria
cases and deaths.
Progress in implementation of IRS. IRS programmes have also
expanded considerably in recent years, with the number of people
protected in the African Region increasing from 10 million in 2005
to 73 million in 2009, a quantity which corresponds to protection for
10% of the population at risk.
In countries in other WHO Regions, the number of ITNs delivered
by manufacturers or distributed by NMCPs is smaller than in Africa,
but has been increasing at a similar rate. However, IRS implementa-
tion has not been expanding as rapidly as in Africa, and is generally
relatively stable. With the exception of India, the proportion of the
population protected by IRS tends to be smaller than in the African
countries which use IRS. The less extensive use of vector control may
reflect the more focal nature of malaria outside Africa.
Potential for insecticide resistance. Current methods of malaria
control are highly dependent on a single class of insecticides, the
pyrethroids, which are the most commonly used compounds for IRS
and the only insecticide class used for ITNs. Pyrethroids are excep-
tionally safe, environmentally friendly, and effective compared to
other classes of insecticide used in public health. However, the wide-
spread use of a single class of insecticide increases the risk of mosqui-
toes developing resistance, which could rapidly lead to a major public
health problem. The risk is of particular concern in Africa, where
insecticidal vector control is being deployed with unprecedented
levels of coverage and where the burden of malaria is greatest.
References
1. Flaxman AD et al. Rapid scaling up of insecticide-treated bed net coverage in Africa and its relationship with development assist-ance for health: a systematic synthesis of supply, distribution, and household survey data. PLoS Med., 2010, 7(8): e1000328
2. T. Tanahashi. Health service coverage and its evaluation. Bul-letin of the World Health Organization, 1978; 56: 295–303
3. Eisele TP et al. Assessment of insecticide-treated bednet use among children and pregnant women across 15 countries using standardized national surveys. American Journal of Tropical Medi-cine and Hygiene, 2009, 80: 209-214.
WORLD MALARIA REPORT 2010 25
Chapter 5. Malaria diagnosis and treatment
This chapter considers the extent to which national
programmes have adopted policies for universal diagnostic
testing of suspected malaria cases and examines trends in
the availability of parasitological testing. It then reviews the
adoption of policies and implementation of programmes
for improving access to effective treatment for malaria
and to intermittent preventive treatment of malaria in
pregnancy. Finally it reviews latest trends in drug resistance,
the progress made in withdrawing oral artemisinin-based
monotherapies from the market, and efforts to contain
artemisinin resistance on the Cambodia-Thailand border.
5.1 Diagnosis of malaria
5.1.1 Policy adoption
In early 2010, WHO updated the recommendation on malaria
diagnostic testing for suspected malaria to include children < 5 years
of age. With this revision, all persons of all ages in all epidemiologi-
cal settings with suspected malaria should receive a parasitologi-
cal confirmation of diagnosis by either microscopy or RDT. National
adoption and implementation of policies for diagnosis of malaria by
WHO Region are shown in Table 5.1. Adoption of policies by country
is shown in Annex 4. In 2009, 33 of 43 malaria-endemic countries in
the WHO African Region and 45 of 63 endemic countries in other
Regions reported having adopted a policy of providing parasitologi-
cal diagnosis for all age groups. A total of 16 African countries are
now deploying RDTs at the community level, as are 22 additional
countries in other Regions.
5.1.2 RDTs procured and distributed
The number of RDTs delivered by ministries of health has increased
rapidly from less than 200 000 in 2005 to about 30 million in 2009 (Fig.
5.1), with most RDTs (44%) being used in the African Region followed
by the South-East Asia Region (41%) and Eastern Mediterranean
Region (11%). These totals, however, are likely to underestimate the
quantity of RDTs distributed, as only 21 of the 43 endemic countries
in the African Region reported these data in 2009. The number of
patients receiving an RDT is generally lower than the number of RDTs
delivered to health facilities, possibly because systems for reporting
the number of patients tested with an RDT have not yet been well
developed in many countries.
0
5
10
15
20
25
30
35
2007 2008 2009
milli
ons o
f RDT
s dist
ribut
ed Western Pacific
South-East Asia
Europe
Eastern Mediterranean
Americas
Africa
5.1.3 Microscopic examination undertaken
The number of patients tested using microscopic examination
fell from a peak of 165 million in 2005 to 151 million in 2009 (Fig.
5.2a). The global total is dominated by India which accounted for 104
million slide examinations in 2005 and 94 million in 2009. Decreases
in the number of patients examined by microscopy were reported in
the Region of the Americas (50%), the European Region (20%) and the
African Region (14%), while there was an increase in the Eastern Medi-
POLICY AFRICAN AMERICASEASTERN
MEDITERRANEAN EUROPEANSOUTH-EAST
ASIAWESTERN PACIFIC
GRAND TOTAL
Number of endemic countries/areas 43 23 12 8 10 10 106
Number of P. falciparum endemic countries/areas 42 18 8 9 9 86
Patients of all ages should receive diagnostic test 33 15 7 8 8 7 78
Only patients > 5 years old receive diagnostic test 5 5
RDTs are used at community level 16 7 5 5 5 38
Malaria diagnosis is free of charge in the public sector 25 13 9 8 10 9 74
Figure 5.1 RDTs distributed by WHO Region
TABLE 5.1
ADOPTION OF POLICIES FOR MALARIA DIAGNOSIS BY WHO REGION
26 WORLD MALARIA REPORT 2010
terranean Region (63%) (Fig. 5.2b). Some of the decreases appear
to be due to a reduction in case-loads, particularly in the American
and European Regions, and to increased use of RDTs. However, these
factors do not fully explain the decrease in patients examined by
microscopy in some countries, where the data may reflect weakening
of diagnostic systems or deterioration in reporting.
5.1.4 Parasitological testing in the public sector
The proportion of reported suspected cases receiving a para-
sitological test varies considerably by Region. It is highest in the
American and European Regions followed by South-East Asia (Fig.
5.3). The value for the South-East Asia Region is heavily influenced by
India; if countries other than India are considered then the percent-
age of cases tested is lower but does show an increasing trend over
the past decade, as is also the case for the Eastern Mediterranean and
African Regions.
Outside Africa, most countries within each Region are able to
provide a diagnostic test for more than 80% of suspected cases (Fig.
5.4a), suggesting that interventions to scale up the availability of
testing in public health facilities can be focussed on a small number
of countries. Of 42 countries in the African Region that reported
on testing, the percentage of cases tested was less than 20% in 21
countries. Examination of the numbers of cases affected by the low
testing rates (Fig. 5.4b) suggests that, with the exception of India,
larger countries tend to have lower testing rates. Most countries with
high rates of testing have had a policy of confirming every malaria
case for several years; some countries have recently expanded the
availability of diagnostic testing with some success (Boxes 5.1 and
5.2).
In the African Region in 2009, the number of ACTs distributed
by NMCPs exceeded the number of RDTs procured more than
five-fold, and the total number of tests carried out (microscopy +
RDTs) by a factor of 2.4, indicating that many patients are receiving
ACTs without confirmatory diagnosis. Similarly, a review of African
countries’ estimates of needs for ACTs and RDTs set out in Global
Fund proposals and PMI operational plans indicated that country
estimates of need for ACTs between 2009 and 2011 exceeded the
need for RDTs by a factor of 2.1 (1). This is partly because 12 of the 41
countries reviewed, including the populous countries of the Demo-
cratic Republic of the Congo and Nigeria, had targeted only persons
≥ 5 years of age for diagnostic testing, in keeping with the previous
WHO recommendation, which was extant at the time the review
was undertaken. The review also indicated that while most of the
estimated needs for ACTs were financed, the funding gap for RDTs
was larger. Hence shortfalls in the availability of diagnostic testing
can be at least partly attributed to the relatively recent policy change
as well as failures to plan for and finance the strategy, and not neces-
sarily to inadequate implementation.
5.1.5 Availability of parasitological tests in the private sector
Data reported by ministries of health on the number of RDTs
distributed and/or patients examined by microscopy generally
cover the public sector only. However, approximately 40% of
malaria patients worldwide seek treatment in the private sector,
which includes regulated health facilities, pharmacies and other
retail outlets (2). Information on the extent of parasitological testing
in the private sector is sparse. Country-specific data collected by
Figure 5.2 Number of patients examined by microscopy
Figure 5.3 Proportion of suspected malaria cases attending public health facilities that receive a parasitological test by microsocpy or RDT
Figure 5.4 Number of countries and cases by rate of parasitological testing
Western Pacific
South-East Asia
Europe
Eastern Mediterranean
Americas
Africa0
20
40
60
80
100
120
140
160
180
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Num
ber o
f pat
ients
(in
milli
ons)
Western Pacific
South-East Asia
Europe
Eastern Mediterranean
Americas
Africa0
10
20
30
40
50
60
70
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Num
ber o
f pat
ients
(in
milli
ons)
Perc
enta
ge
0
20
40
60
80
100
120
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009Africa
Americas
Eastern Mediterranean
EuropeSouth-East Asia
Western PacificSouth-East Asia excluding India
Western Pacific
South-East Asia
Europe
Eastern Mediterranean
Americas
Africa0
10
20
30
40
50
60
<20% 20–39% 40–59% 60–79% >80%
% of suspected cases tested by microscopy or RDT
Num
ber o
f cou
ntrie
s
Western Pacific
South-East Asia
Europe
Eastern Mediterranean
Americas
Africa>80%
05
1015202530354045
<20% 20–39% 40–59% 60–79%
% of suspected cases tested by microscopy or RDT
Num
ber o
f sus
pect
ed ca
ses (
mill
ions
)
a) Number of countries
a) Including India
b) Number of suspected cases
b) Excluding India
WORLD MALARIA REPORT 2010 27
Figure 5.5 Proportion of treatment outlets offering diagnostic testing service
Perc
enta
ge
0102030405060708090
100
Public Private Public Private Public Private Public Private Public Private Public Private Public PrivateBenin Cambodia DR Congo Madagascar Nigeria Uganda Zambia
Microscopic diagnostic testing
Rapid diagnostic testing (RDTs)
Malaria is endemic throughout Senegal. Until 2007, confirmatory malaria diagnosis was limited to hospitals and, of 1.5 million fever cases treated as malaria, only 3% were confirmed as malaria by microscopy. From September 2007, RDTs were incorporated into a revised national policy for management of febrile illness and introduced in all public sector health facilities beyond hospital level, i.e. in 78 health centres, 1018 health posts and subsequently in all 1640 health huts.
The RDTs were initially piloted on a limited scale by the NMCP and the University of Cheikh Anta Diop in Dakar, during which training materials were developed based on generic job-aids and training manuals available from WHO. To ensure appropriate targeting of RDTs, febrile patients were considered for malaria testing only if signs of other possible causes of fever were absent (e.g. cough, sore throat, skin rash). If positive for malaria, patients were prescribed an antimalarial, and if negative, broad spectrum antibiotics (trimethoprim-sulfamethoxazole or amoxycillin) and antipyretics were prescribed.
As part of the wide-scale introduction of RDTs, health workers were trained by district and regional management teams assisted by the NMCP and the University. Data on malaria morbidity and RDT and ACT use are reported by all health units and entered by month into a simple database (Epi Info Version 6). District supervisers cross-check reported data against health facility records during quarterly or bi-annual supervisory visits, and data received from each district are reviewed at quarterly meetings of NMCP personnel and regional and district management staff. The quality of all malaria RDTs is checked after arrival in Senegal through lot-testing at the parasitology laboratory of the University of Anta Cheikh Diop prior to distribution to the field, based on the protocol of the WHO Methods Manual (3).
From 2007 to 2009 the total number of malaria-like fevers decreased from 1.4 million in 2007 to 584 000 in 2009, possibly as a result of revised case definitions of malaria-like fever. During this period the number of patients given a parasitological test rose from 124 000 in 2007 to 503 000 in 2009, covering 86% of malaria-like fevers. The number of confirmed malaria cases rose from 53 000 in 2007 to 175 000 in 2009 because of the increased use of testing.
During this period the number of treatment courses of ACT dispensed fell from 990 000 to 184 000. Whereas ACT treatment consumption in previous years had matched the total number of fever cases, by the end of 2009 it was close to the number of confirmed malaria cases. An estimated 0.5 million courses of inappropriately prescribed ACT were averted between 2008 and 2009.
The experience in Senegal demonstrates that parasitological diagnosis with RDTs can be introduced on a national scale and that with a high level of adherence to diagnostic results, dramatic reductions in ACT consumption can be achieved. Although cost savings in ACT procurement are partly offset by the cost of RDTs, the policy allows: (i) enhanced management of non-malarial febrile illness; (ii) greater certainty on the incidence of malaria throughout Senegal, enabling the NMCP to predict accurately the antimalarial drug requirements and target programme resources to areas with greatest malaria burden; and (iii) the NMCP to assess the impact of changes in malaria control interventions such as ITN and IRS.
0
50
100
150
Num
ber o
f cas
es (i
n th
ousa
nds)
200
250
300
Feb. Apr. Jun. Aug. Oct. Dec. Feb. Apr. Jun. Aug. Oct. Dec. Feb. Apr. Jun. Aug. Oct. Dec.
2007 2008 2009
Number of reported fever cases (suspected malaria)
Number of patients tested (microscopy/RDTs)
Number of malaria cases confirmed (microscopy/RDTs)
Number of patients treated with ACTs
Figure Box 5.1 Trends in suspected, tested, confirmed and treated cases, Senegal 2007–2009
BOX 5.1
EXPANDING ACCESS TO DIAGNOSTIC TESTING IN SENEGAL
28 WORLD MALARIA REPORT 2010
1. www.actwatch.info
2. Information on adoption of the WHO policy on ACTs and their deployment (i) country adoption of ACTs: the WHO/GMP Antimalarial Drug Policies Database (http://www.who.int/malaria/am_drug_policies_by_region_afro/en/index.html); and (ii) country deployment of ACTs to general health services: compiled by the GMP Supply Chain Management Unit on the basis of reports from WHO regional and country offices.
3. WHO monitors the global supply of and demand for the artemether–lumefantrine fixed-dose combination as part of the requirements of the Memoran-dum of Understanding signed with the manufacturer Novartis in 2001, in order to make Coartem® available at cost price for distribution in the public sector of malaria-endemic developing countries.
4. Information on past AL sales for public sector use was obtained from manufacturers eligible for procurement by WHO in 2009, i.e. Ajanta, Cipla, Ipca, Novartis.
ACT Watch1 in 2009–2010 suggest that: (i) in four countries (Benin,
Cambodia, Madagascar and Zambia) RDTs are available in more than
60% of public facilities; (ii) with few exceptions, both microscopy and
RDTs are more widely available in the public sector; and (iii) apart
for Cambodia, availability of RDTs in the private sector remains low
(Fig. 5.5).
5.2 Treatment of malaria
5.2.1 Policy adoption for malaria treatment
By the end of 2009, ACTs had been adopted as national policy for
first-line treatment in 77 of 86 countries with P. falciparum; chloro-
quine is still used in some countries in the Region of the Americas.
By mid-2010, 70 countries were deploying these medicines within
their general health services, with varying levels of coverage.2 Table
5.2 and Annex 4 summarize, respectively, the adoption of policies for
the treatment of malaria by WHO Region and by country.
Malaria has long been a leading cause of mortality and morbidity in the Lao People’s Democratic Republic although the intensity of malaria transmission varies considerably across the country, ranging from very low in the plains along the Mekong River and in areas at high altitude, to intense in remote, hilly and forested areas.
Between 2005 and 2008, the national malaria programme introduced a strategy to improve case management at the community level by training approximately 12 000 village health volunteers in 6202 villages. These volunteers constitute the most peripheral level of the public health care system in Lao PDR. Volunteers are selected by the village committee to provide primary health care services, including diagnosis of malaria by RDT and administration of ACT, providing health education, distributing ITNs, and reporting morbidity and mortality data to health centres and the district health office.
The composition of cases has changed radically since the beginning of the decade. Whereas the vast majority used to be diagnosed only on a clinical basis (“probable cases”) almost all cases of P. falciparum malaria are now confirmed. Although records of drug consumption are not available, confirmation of cases is likely to have reduced the consumption of ACTs.
While changing diagnostic practices make it difficult to discern trends, large reductions in numbers of cases are believed to have
occurred as a result of increased ITN coverage (81% of children < 5 years slept under ITNs in 2009) and improved access to treatment. The number of recorded deaths from malaria has fallen from 350 in 2000 to 5 in 2009.
Diagnosis will be extended at village level to include P. vivax through the use of combination RDTs, and radical treatment is to be introduced in parallel to an expansion of a private-public mix initiative for malaria diagnosis and treatment in the private sector.
0
2000
4000
6000
8000
10 000
12 000
14 000
16 000
18 000
20 000
2005 2006 2007 2008
Num
ber o
f mala
ria ca
ses
0
50 000
100 000
150 000
200 000
250 000
300 000
Num
ber o
f sus
pect
ed ca
ses t
este
d
Probable malaria cases
Tested by microscopy or RDT
Confirmed malaria cases
5.2.2 Quantity of ACTs procured and distributed
The number of ACT treatment courses procured increased
greatly from 11.2 million in 2005 to 76 million in 2006, and reached
158 million in 2009. Procurement of four WHO-recommended ACTs
by ministries of health from 2005 to 2009 is shown in Figure 5.6.
Artemether-lumefantrine (AL) accounts for the largest volume of
ACTs procured by the public sector (67%) in 2009. 3 The second ACT
in terms of volumes procured is artesunate + amodiaquine, which
increased from less than 1 million treatment courses in 2007 to 23.2
million in 2009.
Between 2006 and 2008, most AL was procured for young children
weighing less than 15 kg, and the smallest proportion was supplied
for patients with a body weight of 25–34 kg. In 2009, a changing trend
was observed, with an increasing proportion procured for patients
with a body weight over 35 kg and a corresponding decrease in
supplies for young children weighing less than 15 kg)4 (Fig. 5.7).
Figure Box 5.2 Trends in tested, probable and confirmed cases, Lao PDR, 2001–2008
BOX 5.2
EXPANDING ACCESS TO DIAGNOSIS AND TREATMENT IN LAO PEOPLE’S DEMOCRATIC REPUBLIC
WORLD MALARIA REPORT 2010 29
0
20
40
60
80
100
120
140
160
2005 2006 2007 2008 2009
Num
ber o
f tre
atm
ent c
ours
es (i
n m
illion
s)
AL
AS-AQ (FDC)
AS+AQ (Co-B)
AS+MQ
AS+SP
Num
ber o
f tre
atm
ent c
ours
es (i
n m
illion
s)
0
20
40
60
80
100
120
2006 2007 2008 2009
AL 5-14 kg
AL 15-24 kg
AL 25-34 kg
AL 35+ kg
BOX 5.3
ARTEMISININ MARKET SITUATION
The agricultural production of Artemisia annua and the extraction and supply of artemisinin are still characterized by market instability. The major investments and expansion in cultivation of Artemisia annua and production of artemisinin in 2006–2007 were not matched by a similar increase in demand for artemisinin by ACT manufacturers and suppliers of artemisinin-based active pharmaceutical ingredients. The resulting production surplus of artemisinin led to a reduction in the prices of artemisinin raw material, even falling below production costs, reaching as low as US$ 170 per kg by the end of 2007. This led to the withdrawal of many artemisinin producers from the market in 2008 and 2009, creating a progressive reduction in existing inventories and a relative decrease in supply. Together with the increasing global demand for ACTs, this produced a progressive increase in the spot prices of artemisinin, reaching US$ 350 per kg by the end of 2009.
To stabilize these market dynamics, in 2009 a UNITAID-funded initiative was introduced, the Assured Artemisinin Supply System (A2S2), to provide low interest rate credits to artemisinin extractors who are linked to ACT manufacturers eligible for procurement by WHO and UNICEF. Production of artemisinin-based antimalarial medicines will remain dependent on cultivation of Artemisia annua, as production of semi-synthetic artemisinin derived from yeast cultures will not become available until at least 2012, and will only cover part of the global market requirements.
0
200
400
600
800
1000
1200
2002 2003 2004 2005 2006 2007 2008 2009
US$
per k
g
POLICY AFRICAN AMERICASEASTERN
MEDITERRANEAN EUROPEANSOUTH-EAST
ASIAWESTERN PACIFIC
GRAND TOTAL
Number of endemic countries/areas 43 23 12 8 10 10 106
Number of P. falciparum endemic countries/areas 42 18 8 9 9 86
ACT is used for treatment of P. falciparum 42 9 8 9 9 77
ACT is free of charge for all age groups in public sector 24 6 9 6 7 52
ACT is free of charge only for < 5 years in public sector 5 2 1 8
ACT delivered at community level 25 2 1 4 4 36
Pre-referral treatment with quinine/artemether IM/ artesunate suppositories
32 2 7 7 6 54
Therapeutic efficacy monitoring is undertaken 25 6 5 5 7 48
Figure 5.6 ACT sales to the public sector (2005–2009) by artemisinin-based combination (data provided by
Figure 5.7 Artemether-lumefantrine: public sector sales, 2006–2009
Figure Box 5.3 Artemisinin indicative spot prices (US$/kg)
TABLE 5.2
ADOPTION OF POLICIES FOR MALARIA TREATMENT IN WHO REGIONS
30 WORLD MALARIA REPORT 2010
5.2.3 ACTs distributed by ministries of health
The number of ACTs distributed by NMCPs also appears to have
increased between 2007 and 2009 but reporting by countries in
incomplete so that totals do not match those delivered by manufac-
turers. Nevertheless, country reports indicate that by the end of 2009,
11 African countries were providing sufficient courses of ACTs to cover
more than 100% of malaria cases seen in the public sector; a further
8 African countries delivered sufficient courses to treat 50%–100%
of cases. These figures represent a substantial increase since 2005,
when only 5 countries were providing sufficient courses of ACT to
cover more than 50% of patients treated in the public sector.
5.2.4 Availability of ACTs in treatment outlets
ACT Watch data summarizes the availability of antimalarial
medicines in public and private sector treatment facilities5 in 7
countries in 2009–2010). The results suggest that, although disrup-
tions in supplies are common in both the public and private sectors,6
there is wide variation in the availability of antimalarials by country
and type of facility/outlet. In 4 countries, the first-line treatment is
available in more than 80% of public health facilities and at lesser
y = 0.65 x – 0.016R2 = 0.68
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80 90 100% patients attending public health facilities needing antimalarial medicine
% ch
ildre
n <
5 at
tend
ing p
ublic
hela
th fa
ciliti
es
rece
iving
an
antim
alaria
l med
icine
(%)
% receiving = % need
Fitted line
5. Treatment outlets comprise any place where patients seek treatment for malaria such as hospitals, health centres, health posts, pharmacies, shops or kiosks.
6. Stock-out of first-line treatment for one week within past three months.
Perc
enta
ge
0102030405060708090
100
Benin Cambodia DR Congo Madagascar Nigeria Uganda Zambia
First-line treatment
Non-artemisinin monotherapy
SP Oral artemisinin monotherapy
Perc
enta
ge
First-line treatment
Non-artemisinin monotherapy
Oral artemisinin monotherapy
0102030405060708090
100
Benin Cambodia DR Congo Madagascar Nigeria Uganda Zambia
Figure 5.8 Availability of antimalarial medicines
a) In public sector health facilities
b) In private sector treatment outlets
rates in the 3 other countries. In the private sector, there is 30% avail-
ability or less of the first-line treatment. Unfortunately, artemisinin
monotherapies are also being stocked in some countries and in
some instances are available in more than 30% of private outlets
(Fig. 5.8).
In most countries, the private sector dispensed the predominant
proportion of antimalarials. The first-line treatment represented less
than 10% of the drugs dispensed through the private sector (except
Cambodia at 17%) with non-artemisinin monotherapies representing
the largest proportion of volumes. In the public sector, sulfadoxine-
pyrimethamine accounts for the majority of non-artemisinin drugs
dispensed (Fig. 5.9)
First-line treatments were found to be 4–22 times more expensive
(median price US$ 4.96) than the most commonly dispensed drug,
which for all countries is a non-artemisinin treatment (median price
US$ 0.37). Since the price of an antimalarial will greatly affect its
utilization, efforts are being made to reduce the price of ACTs to a
consumer price equivalent to that of non-artemisinin therapies, by
enabling wholesalers to buy ACTs at a subsidized price though a pilot
initiative known as the Affordable Medicine Facility – malaria (AMFm)
(Box 5.4).Pe
rcen
tage
0102030405060708090
100
Public Private Public Private Public Private Public Private Public Private Public Private Public Private
Benin Cambodia DR Congo Madagascar Nigeria Uganda Zambia
First-line ACT Other ACTsSP (public) Non-artemisinin monotherapies (incl. SP in private)Non-oral artemisinin monotherapy Oral artemisinin monotherapy
Figure 5.9 Relative volumes of antimalarials distributed by sector and drug type
Figure 5.10 Proportion of children receiving antimalarial medicine in relation to percentage of patients requiring antimalarial medicine
WORLD MALARIA REPORT 2010 31
BOX 5.4
THE AFFORDABLE MEDICINES FACILITY – MALARIA
The Affordable Medicines Facility – malaria (AMFm) is a financing mechanism designed to expand access to ACTs. It is managed by the Global Fund and supported financially by the Bill & Melinda Gates Foundation, the United Kingdom Government, UNITAID and the Global Fund.
AMFm aims to increase the provision of high quality and affordable ACTs by: (i) negotiating a lower price for ACTs; (ii) paying a subsidy directly to manufacturers on behalf of buyers (a buyer “co-payment”); (iii) supporting interventions to encourage the appropriate use of ACTs (4). The price reductions and subsidies mean that buyers will only pay approximately US$ 0.05 for each course of ACTs. For patients who currently pay for treatment, this is expected to result in a significant reduction in the price of ACTs from about US$ 6–10 per treatment to about US$ 0.20–0.50. The increased availability of affordable ACTs is intended to save lives by making ACTs more readily available and reducing the use of less effective treatments to which malaria parasites are becoming increasingly resistant. It also aims to reduce the use of oral artemisinin monotherapies, thereby delaying the onset of resistance to that drug and preserving its effectiveness. The current AMFm model does not include the routine use of diagnostic testing, which could result in the overuse of ACTs among patients with non-malarial febrile illnesses, especially in countries with declining malaria transmission.
A pilot trial of AMFm has been launched in a small group of countries to enable lessons to be learnt before any expansion of the initiative to other malaria-endemic countries is envisaged. The countries participating are Cambodia, Ghana, Kenya, Madagascar, Niger, Nigeria, UR Tanzania (mainland and Zanzibar) and Uganda. The pilot study will operate for approximately 24 months and will be reviewed through an independent evaluation. The Global Fund Board will consider the results of the evaluation and determine whether to expand, accelerate, modify or suspend AMFm. It is expected that the Board will make this decision in 2012.
7. A high correlation is observed whether or not an adjustment is made for population at risk in the formula for Ms.
It is however possible to combine information from household surveys
with information from routine information systems to determine the
percentage of patients tested and the percentage of positive tests,
in order to estimate the needs for treatment. Box 5.5 describes how
a rough estimate of treatment needs for children attending public
health facilities can be constructed.
Figure 5.10 summarizes information from 37 countries (18 in sub-
Saharan Africa) in which household survey information on antima-
larial use and concurrent information on diagnostic testing in public
sector health facilities is available. It shows that the percentage of
patients attending public health facilities who need an antimalarial
medicine varies enormously by country and year, being lower in less
endemic countries outside Africa where the percentage requiring an
antimalarial is often less than 20%.
Meeting the treatment needs. Figure 5.10 shows also the percentage
of febrile children that receive an antimalarial is correlated with the
estimate of percentage of patients requiring an antimalarial7 (R2 =
0.68), i.e. countries with the lowest uptake of antimalarial medicines as
measured through household surveys are often the countries where
fewer febrile patients actually have malaria. However, there is a wide
scatter of points, with most lying below the line that defines where
treatment uptake is equal to need. Thus it appears that for many
countries the number of children receiving antimalarial medicines is
less than the predicted need (on average, treatment uptake is 65% of
treatment need).
Some countries such as Chad (2004), Liberia (2007), Rwanda
(2007), United Republic of Tanzania (2004), and Zimbabwe (2005)
appeared to be fulfilling antimalarial needs (the percentage of
children requiring an antimalarial being close to the percentage of
patients receiving one). However, whereas almost all cases received
a diagnostic test in Liberia and Rwanda, only 45% did so in United
Republic of Tanzania and less than 1% in Chad. Hence the percentage
of patients requiring an antimalarial in Chad and in United Republic
of Tanzania could have been reduced if diagnostic testing were made
more widely available in the public sector.
In some countries, such as Congo (2007), Sierra Leone (2008), and
Uganda (2002), the percentage of children that received an antima-
larial (< 20%) appears to be much less than the percentage requiring
one (> 60%) suggesting shortfalls in the availability of antimalarial
medicines in the public sector at the time of the survey.
Patients not using public sector health facilities. It is more difficult
to determine what percentage of fever cases should receive an anti-
malarial among those attending private sector facilities, or among
those who do not seek treatment in any health facility. It is never-
theless instructive to compare the percentage of febrile children
receiving an antimalarial in the private sector with that observed for
the public sector. Figure 5.11 shows that febrile children attending
private sector treatment facilities are generally only 75% as likely to
receive an antimalarial medicine as those attending public sector
facilities, and that the corresponding rate for children who are not
treated in any health facility is 40%. Evidently, a significant propor-
tion of those not treated in a health facility have access to antima-
larial medicines at home. Information on the percentage of children
receiving an ACT is less readily available, as relevant questions were
not asked in household surveys until more recent years. However,
children attending private sector facilities also appear less likely to
5.2.5 Utilization of antimalarial medicines to treat febrile children
Policy. A central question regarding the utilization of antimalarial
medicines is whether people in need of these medicines actually
receive them. The need for antimalarial medicines will depend on
diagnostic practices and the treatment policies existing within a
country. WHO recommends that antimalarial medicines should be
given only to patients who have had a positive parasitological test.
However, patients with suspected malaria who do not receive a para-
sitological test may be given an antimalarial medicine, depending on
the treatment policy of the country. In high burden African countries
most treatment policies allow for antimalarial medicines to be given
to children < 5 years of age in situations where a diagnostic test
cannot be provided.
Estimation of needs. The use of antimalarial medicines is recorded
in household surveys but information on diagnostic testing, and
therefore treatment needs, is not available in most of these surveys.
32 WORLD MALARIA REPORT 2010
receive an ACT than in the public sector (on average about 70% as
likely) while those not treated in a health facility are only 15% as likely
to receive an ACT.
The lower proportion of children who received an antimalarial when
treated at home may be appropriate if fevers are transient, or consid-
ered by caregivers to be less serious and not requiring medication, but
may be of concern if the reason were lack of access to facilities or too
An estimate of the need for antimalarial medicines among patients attending public health facilities can be obtained from routine information on the percentage of patients receiving a parasitological test and the percentage testing positive. The estimated need can then be compared with the percentage of febrile children actually receiving an antimalarial medicine as recorded in a DHS or other heath survey.
For example, in Rwanda in 2005 health facility records indicated that 87% of suspected malaria cases attending public health facilities received a parasitological test, of which 48% tested positive. Hence, it can be estimated that 55% of children attending public health facilities in Rwanda required an antimalarial (13% who were not tested plus 87% x 48% who tested positive). This can be compared to the 31% of children attending public health facilities who actually received an antimalarial medicine. It therefore appears that the percentage of children receiving an antimalarial medicine compared to those needing one was 57% (31%/55%).
A comparison of the results in 2005 with those obtained in 2008 shows important developments over this period. The percentage of patients with suspected malaria who received a parasitological test increased to 100% while only 22% were test positive. Thus the percentage of patients attending public sector facilities that needed an antimalarial medicine was 100% x 22% or just 22%. The percentage of children attending public facilities who received an antimalarial was recorded as 16%. The percentage of need that had been fulfilled had therefore increased to 75% (16%/22%) despite the overall percentage of children receiving an antimalarial having decreased. This is largely because the percentage of suspected malaria cases testing positive for malaria had dropped from 48% to 22% owing to decreasing incidence of malaria as a result of control activities.
In general a national estimate of the percentage of patients requiring an antimalarial, Mf, in public health facilities can be calculated from routine data as:
Mf = (St × T) + Sn
where: St = percentage of suspected cases tested
T = percentage of tests positive
Sn = percentage of suspected cases not tested and treated presumptively
This indicator can then be compared with the percentage receiving an antimalarial in public sector facilities, Ms as measured in a household survey:
Ms = A ÷ R
where: A = percentage of febrile children taken to public health facilities that receive an antimalarial medicine R = population at risk of malaria
Such a comparison provides a rough assessment of whether the need for antimalarial medicines in public health facilities is being fulfilled. It does not consider the specific test results of individuals or the treatment they were given but simply examines statistics at an aggregate level. In addition household survey data are restricted to children under 5, whereas data on the percentage of suspected malaria cases that are test positive are usually only available for all age groups combined. Moreover the analysis does not consider whether health workers withheld a test because other symptoms were present and another diagnosis given.
It is more difficult to determine whether the percentage of febrile children receiving an antimalarial is appropriate for those treated in private sector facilities or those who are not treated in any health facility. More information is required on both the extent of parasitological diagnosis in the private sector and the proportion of tested cases which are positive. Information on the incidence of malaria among those who do not seek treatment is also required; some insight could be derived from malaria indicator surveys that undertake parasitological testing. Unfortunately datasets from many of such surveys are not readily available for analysis.
0 20 40 60 80 100
Received parasitological test
Need antimalarial(positive test
or untested)
Receivedantimalarial
% of cases in public sectorRwanda 2005
0 20 40 60 80 100
Received parasitological test
Need antimalarial(positive test
or untested)
Receivedantimalarial
% of cases in public sectorRwanda 2008
high a cost for treatment. In settings where active case detection has
been conducted, slide positivity rates are generally about 50% of the
rates observed during passive case detection. Hence, the lower rate
of treatment utilization among those who are not treated in a health
facility may be appropriate. However, from the information available
there is no assurance that children who receive antimalarial medicines
are those who are parasite-positive and in need of treatment.
Figure Box 5.5 Percentages of fever cases attending public sector facilities that (i) receive a diagnostic test, (ii) require an antimalarial medicine and (iii) receive one, Rwanda 2005 and 2008
BOX 5.5
ESTIMATING NEEDS FOR ANTIMALARIAL MEDICINES IN THE PUBLIC SECTOR AND COMPARISON WITH USE
WORLD MALARIA REPORT 2010 33
Percentage0 10 20 30 40 50 60 70 80 90 100
GuineaSierra Leone
CongoMadagascar
TogoGambia
Burkina FasoNiger
KenyaCameroon
SenegalZambia
MozambiqueMali
GhanaAngola
DR CongoUganda
MauritaniaGuinea-Bissau
Equatorial GuineaGabon
y = 0.7543 x + 0.0007R2 = 0.8547
y = 0.3924 x – 0.0055R2 = 0.666
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100 % of febrile children attending public sector facilities that receive an antimalarial medicine
% of
febr
ile ch
ildre
n at
tend
ing p
rivat
e sec
tor f
acilit
iesor
stay
ing a
t hom
e th
at re
ceive
an
antim
alaria
l med
icine
Private sector Staying at home
y = 0.7917 x – 0.0177
R2 = 0.8145
y = 0.1445 x – 0.0005
R 2 = 0.704
Private sector Staying at home
0
5
10
15
20
25
30
35
0 5 10 15 20 25 30 35% of febrile children attending public sector facilities that receive an ACT
% of
febr
ile ch
ildre
n att
endin
g priv
ate s
ector
facil
ities
or s
taying
at h
ome t
hat r
eceiv
e an
ACT
Percentage0 10 20 30 40 50 60 70
Zambia, 2007 DHS
Senegal, 2008 MIS
Liberia, 2009 MIS
Rwanda, 2008 DHS
Kenya, 2008 DHS
Madagascar, 2008 DHS
Nigeria, 2008 DHS
Angola, 2007 MIS
care receiving the second dose of IPTp was 55% (inter-quartile range
47%–61%) (Fig. 5.12). Thus half of women attending antenatal clinics
received a second dose of IPTp in those countries responding.
Although not all pregnant women attend antenatal clinics, infor-
mation on the percentage of all pregnant women receiving the
second dose of IPTp can be derived from household surveys. Data on
IPTp for pregnant women from surveys in 2007–2009 were available
for 8 countries in Africa representing a combined population of 270
million. In 2007–2009, the percentage of women who received two
doses of treatment during pregnancy ranged from 2.4% in Angola
to 62% in Zambia (Fig. 5.13); the weighted average remained low, at
12% due to low coverage rates in Nigeria.
POLICY AFRICAN AMERICASEASTERN
MEDITERRANEAN EUROPEANSOUTH-EAST
ASIAWESTERN PACIFIC
GRAND TOTAL
Number of endemic countries/areas 43 23 12 8 10 10 106
Number of P. falciparum endemic countries/areas 42 18 8 9 9 86
IPTp used to prevent malaria during pregnancy 33 2 1 36
Figure 5.11 Proportion of febrile children receiving an antimalarialmedicine by source of treatment
Figure 5.13 Proportion of all pregnant women receiving the second dose of IPT
Figure 5.12 Proportion of women attending antenatal care receiving the second dose of IPT
a) Any antimalarial medicine
b) Artemisinin combination therapy
5.3 Intermittent preventive treatment A total of 33 of 43 endemic countries in the African Region had
adopted intermittent preventive treatment for pregnant women
(IPTp) as national policy by the end of 2009, with two in the Eastern
Mediterranean Region (Somalia and Sudan), and one in the Western
Pacific Region (Papua New Guinea) (Table 5.3). No country has yet
adopted a national policy of intermittent preventive treatment for
infants (IPTi).
For 22 of the 35 high-burden countries, consistent data were
available on both the second dose of IPTp (numerator) and the number
of women who had attended antenatal care at least once (denomina-
tor) for 2009. The median percentage of women attending antenatal
TABLE 5.3
ADOPTION OF POLICIES FOR INTERMITTENT PREVENTIVE TREATMENT FOR PREGNANT WOMEN (IPTp)
Source:
Source: household survey data
34 WORLD MALARIA REPORT 2010
5.4 Antimalarial drug resistance
5.4.1 Oral artemisinin-based monotherapy medicines
The use of oral artemisinin-based monotherapies threatens
the therapeutic life of ACTs by fostering the spread of resistance to
artemisinin. To contain this risk and to ensure high cure rates for P.
falciparum malaria, WHO recommends the withdrawal of oral artem-
isinin-based monotherapies from the market and the use of ACTs
instead, as endorsed by the World Health Assembly in 2007 (Box 5.6).
It also calls upon manufacturers to cease production and marketing
of oral artemisinin-based monotherapies.
WHO compiles data on both manufacturers’ compliance and
the regulatory action taken by malaria-endemic countries and the
data are posted on the Internet.8 Nearly all companies which have
a consistent market share in public sector procurement funded by
international agencies have de-listed oral artemisinin-based mono-
therapy medicines from their product catalogues. However, smaller
companies mainly targeting private sector markets are less likely to
comply with the WHO appeal. When responsible companies withdraw
their monotherapy products, they leave "niche markets" which are
rapidly exploited by other companies manufacturing monotherapies.
One of the main reasons for the limited success in phasing out oral
artemisinin-based monotherapy is the weak regulation of pharma-
ceutical markets in malaria-endemic countries. By November 2010,
25 countries were still allowing the marketing of these products and
39 pharmaceutical companies were manufacturing these products.
Most of the countries that still allow the marketing of monotherapies
are located in the African Region, while most of the manufacturers of
these medicines are located in India (Fig. 5.14).
Greater collaboration and involvement of national regulatory
authorities is required to ensure complete withdrawal of oral artem-
isinin-based monotherapies from all countries. Progress made by
several pharmaceutical companies and regulatory authorities at
country level shows that phasing out oral artemisinin-based mono-
therapy medicines from the markets is possible through a range of
interventions. Based on their experience, a generic series of actions
has been developed to remove oral artemisinin-based monotherapy
medicines from the market (Box 5.7).
5.4.2 Drug efficacy monitoring
Therapeutic efficacy studies remain the gold standard for guiding
drug policy. WHO compiles the results of efficacy tests conducted
by national malaria programmes in the WHO Global Database on
Antimalarial Drug Efficacy. The database, which now contains over
4000 studies conducted between 1996 and 2010, formed the basis
of the Global report on antimalarial drug efficacy and drug resist-
ance: 2000–2010 (5), from which the following summary has been
extracted.
Treatment of P. falciparum malaria: major findings related to the
development of drug resistance for the treatment of P. falciparum
globally are:
amodiaquine, 6 countries have reported at least one study with
a high level of treatment failure (> 10%). A high level of treatment
failure for this combination was also observed in four Indonesian
studies.
where mefloquine resistance is prevalent, for example in the
Greater Mekong region. In Africa and the Americas, the combina-
tion remains highly effective.
fec tive in those countries that are using this combination as a first-
line treatment. Failure rates remain high in those regions where
resistance to sulfadoxine-pyrimethamine is high.
of the world, with the exception of Cambodia. More studies are
needed to determine the current state of the efficacy of artemeth-
er-lumefantrine in Africa, as over 85% of the studies included in
the database were completed in 2007 or earlier.
-
aquine are limited and come mainly from studies carried out in
some parts or Africa and in the Greater Mekong subregion. More
studies are needed before drawing conclusions about its overall
efficacy in endemic countries.
Num
ber o
f cou
ntrie
s
0
5
10
15
20
AFRO EMRO EURO AMRO SEARO WPRO
BOX 5.6
WORLD HEALTH ASSEMBLY RESOLUTION WHA60.18
In May 2007, the 60th World Health Assembly resolved to take strong action against oral artemisinin-based monotherapies and adopted resolution WHA60.18, which:
both the public and private sectors of oral artemisinin-based monotherapies, to promote the use of ACTs, and to implement policies that prohibit the production, marketing, distribution and the use of counterfeit antimalarial medicines;
adjust their policies so as progressively to cease to fund the provision and distribution of oral artemisinin monotherapies, and to join in campaigns to prohibit the production, marketing, distribution and use of counterfeit antimalarial medicines.
The full text of the resolution can be found on the Internet at: http://apps.who.int/gb/ebwha/pdf_files/WHA60/A60_R18-en.pdf.
Figure 5.14 Number of countries allowing marketing of oral artemisinin-based monotherapies by WHO Region
8. Information is available on the internet via the following links: Manufacturing companies: http://www.who.int/malaria/monotherapy_manufacturers.pdf National Regulatory Authorities: http://www.who.int/malaria/mono-therapy_NDRAs.pdf
WORLD MALARIA REPORT 2010 35
The first evidence of resistance to artemisinins on the Cambodia-Thailand border emerged from routine efficacy testing in 2006. This finding prompted WHO, the health ministries of Cambodia and Thailand, and other partners to develop a project aiming to contain and eliminate resistant parasites from the area. The Bill & Melinda Gates Foundation provided US$ 22.5 million to fund the first two years of activities, starting in 2009.
The project uses a combination of prevention and treatment methods and is implemented in two zones. Zone 1 covers populations in which artemisinin tolerance has been detected, including about 270 000 people in Cambodia and 110 000 people in Thailand. Zone 2 covers areas where there is as yet no evidence of tolerance, but the risk is high because it is close to Zone 1; it covers more than 4 million people in Thailand and 150 000 people in Cambodia.
The project has distributed more than 260 000 LLINs in Zone 1, allowing every person to sleep under a mosquito net each night. In Zone 2, where 320 000 LLINs have been distributed, 100% coverage has also been achieved in the high-risk villages.
The sale of artemisinin monotherapies was banned by the Cambodian Department of Drugs and Food in March 2009. Approximately 250 “justice police” were trained to enforce the law against counterfeit drugs and the ban on the sale of monotherapies. All private pharmacies, shops and outlets dispensing drugs in Pailin were registered and are regularly inspected. Workshops were held with retailers of antimalarial medicines to raise awareness of the ban and the problems associated with monotherapies.
All villages in Zone 1 and all high-risk villages in Zone 2 have access to early diagnosis and treatment provided free of charge by trained village malaria workers – about 2900 were trained in
Cambodia and 326 in Thailand. The volunteer malaria workers also provide community-based education programmes, raising awareness about the use of mosquito nets, the dangers of fake drugs, and how to access reliable treatment. Education materials such as posters, brochures, and billboards have been produced in both Thai and Khmer, with the Khmer materials available on both sides of the border.
Systems to monitor the cross-border movements of Cambodians and Thais have been developed in order to track possible movement of the malaria parasites. The health departments of Cambodia and Thailand share information to coordinate actions and follow up cases.
An intense screening and treatment programme is being conducted in 20 high-risk villages in Pailin which screens all men, women and children in a village, even those not showing symptoms of malaria. Samples are sent by taxi to the Pasteur Institute in Phnom Penh where they are examined using PCR to determine whether malaria parasites are present. In the first seven villages screened – from May to late June 2010 – almost 2800 people were tested and only two cases of P. falciparum malaria were found. Six of the seven villages had no cases of P. falciparum malaria. Only one year previously these seven villages were among the most affected by malaria in the border area. Two other sources of data – from the Cambodian Ministry of Health and from the village malaria workers – also showed that cases of P. falciparum malaria in the zone targeted by the project had fallen dramatically. The interventions to combat malaria in the target area therefore appear to be having an impact.
For more details see: http://www.who.int/malaria/diagnosis _ treatment/arcp/en/index.html
BOX 5.7
RECOMMENDED STEPS TO REMOVE ORAL ARTEMISININ-BASED MONOTHERAPY MEDICINES FROM THE MARKET
ACTION TASK TIMELINEStep 1 Agreement on time frame for phasing out oral artemisinin-based monotherapies in synchrony with large-scale implementation
of artemisinin-based combination therapies (ACTs).Step 2Step 3 3–4 months
Step 4 Large-scale deployment of ACTs in the public sector and communication to prescribers and consumers to move away from monotherapies, generally associated with external funding for procurement (e.g. from Global Fund or other sources). All subsequent timelines are conditional on this.
Time X
Step 5 Widespread availability and affordability of subsidized ACTs in the private sector, as expected in countries participating in the Affordable Medicine Facility.
Time Z
Step 6 6 months after time XStep 7 6 months after time XStep 8 10–12 months after
time XStep 9 Active recall of oral artemisinin-monotherapies from the market. 3 months after time Z
BOX 5.8
THE ARTEMISININ RESISTANCE CONTAINMENT PROJECT
36 WORLD MALARIA REPORT 2010
Cost implications of improved diagnosis: as the incidence of malaria
decreases through much of sub-Saharan Africa the need to differ-
entiate malaria from non-malarial fevers becomes more pressing.
Countries that adopt universal testing will reduce their spending on
ACTs but the savings will be offset by the cost of RDTs and alterna-
tive therapies and the increased time needed by health workers to
examine patients. The total costs to the health system will depend
on the cost of testing, the proportion of suspected malaria cases that
are parasite positive, the sensitivity and specificity of tests, clinicians’
adherence to test results, and the cost of treatment prescribed to
parasite-positive and parasite-negative patients (6). Further work is
needed to understand how costs will change as the availability of
diagnostic testing is increased and to identify the factors NMCPs
need to take into account when planning for expansion of RDT
programmes.
Benefits of expanding diagnosis: several benefits accrue from
increasing diagnostic testing: (i) patients will obtain appropriate
diagnosis and treatment for their illness leading to lower mortality
rates and reduced recovery times; (ii) excessive use of antimalarials
can be reduced which will help to limit the development of resist-
ance to ACTs; (iii) more accurate data on the incidence of confirmed
malaria cases will enable interventions to be targeted to high priority
areas and it will be possible to judge more accurately the success of
programme implementation. The monetary value of such benefits
is uncertain but there is consensus that these are worthwhile objec-
tives for health systems.
Diagnostic testing in the private sector: the challenges involved in
expanding access are likely to be greater in the private sector for
several reasons: (i) the availability of testing is lower; (ii) the private
sector is not so easily regulated by ministries of health; (iii) there is
little experience of expanding diagnostic programmes in the private
sector; (iv) incentives to use diagnostic tests and comply with test
results will depend on costs which will often be borne directly by the
patients. It may be more affordable for a patient to buy an ACT rather
than seek an RDT particularly if the costs of ACTs in the private sector
are reduced through subsidies. More information is needed on how
to scale up availability of diagnostic testing in the private sector.
Community-based diagnosis and treatment: for some remote
communities with little access to public sector or private sector
health care providers, parasitological diagnosis and treatment of
malaria will need to be provided by community based programmes.
Very few such programmes operate on a large scale but the experi-
ence of Lao People’s Democratic Republic and some other countries
suggests that an existing cadre of village health workers can be
trained in the use of RDTs and in large scale provision of appropri-
ate treatment, resulting in dramatic changes in the way malaria case
reporting is undertaken.
Access to treatment: information from manufacturers indicates
that the number of ACTs procured has increased in every year since
2005. However there is little information on whether the quantities
of antimalarial medicines available in public and private sectors are
sufficient to meet the needs of patients. Data provided by malaria-
endemic countries on medicines delivered are often incomplete.
The critical role of monitoring drug efficacy has been demon-
strated on the Cambodia-Thailand border area, where studies
in 2002–2005 by the Cambodia and Thailand national malaria
programmes demonstrated prolonged parasite clearance times
following treatment with ACTs. In 2006–2007, AFRIM detected
two cases of artemisinin resistance in Tasanh, Cambodia,
providing the first evidence of artemisinin resistance. Since 2008,
WHO has been coordinating containment activities in this area,
making significant progress in limiting the spread of artemisinin-
resistant parasites (Box 5.8).
An increase in the proportion of patients still parasitaemic on day
3 following treatment with ACTs has also been reported along the
Thailand-Myanmar and China-Myanmar borders, and in one province
in Viet Nam where the situation is less serious than at the Cambo-
dia-Thailand border, but still merits careful monitoring. While these
observations suggest that there are changes in parasite sensitivity
to artemisinins, ACTs remain clinically and parasitologically effective
even in the Greater Mekong subregion. It is not yet known whether
clearance times will continue to become more prolonged, or how the
prolonged clearance time might put the partner drug at risk for the
development of resistance.
Treatment of P. vivax malaria: chloroquine remains the drug of choice
in areas where chloroquine remains effective. Treatment failure on
or before day 28 and/or prophylactic failures have been observed
in Afghanistan, Brazil, Cambodia, Colombia, Guyana, Ethiopia, India,
Indonesia, Madagascar, Malaysia (Borneo), Myanmar, Pakistan, Papua
New Guinea, Peru, the Republic of Korea, Solomon Islands, Thailand,
Turkey, Sri Lanka, Vanuatu and Viet Nam. However, confirmation of
true chloroquine resistance requires additional drug concentration
studies. For this reason it is not entirely clear to what extent chlo-
roquine-resistant P. vivax has spread. At least one case of chloro-
quine-resistant vivax malaria has been confirmed in Brazil, Ethiopia,
Indonesia, Malaysia (Borneo), Myanmar, Solomon Islands, Thailand,
Papua New Guinea, and Peru. ACTs are now recommended for the
treatment of chloroquine-resistant P. vivax, particularly where ACTs
have been adopted as the first-line treatment for P. falciparum.
5.5 Conclusions
Availability of parasitological diagnosis: there have been significant
increases in the availability of parasitological testing in the last few
years but low rates persist in the majority of African countries and
in a few other countries. A review of commodity procurement plans
suggests that the gap between policy and implementation appears
to be partly due to a failure to adequately plan for and finance the
expansion of RDTs; bottlenecks in implementation may also contrib-
ute.
A small selection of countries have shown that it is possible to rapidly
scale up the availability of malaria diagnostic testing nationwide
within a relatively short period of time, provided that attention is
given to adequate preparation, training, monitoring, supervision and
quality control.
WORLD MALARIA REPORT 2010 37
Household survey data currently do not examine the question
directly. If survey data are combined with health facility data then it
is estimated that on average 65% of treatment needs are fulfilled for
patients attending public health facilities. Estimates are more difficult
to construct for patients visiting private sector treatment outlets and
those that stay at home, but use of antimalarial medicines appears
to be lower than for patients attending public sector facilities. The
scarcity of information on access to treatment highlights the need
to strengthen routine monitoring systems for diagnostic testing
and treatment, to gather more direct information from household
surveys, and to explore other methods to monitor access such as
clinic exit interviews.
Combatting drug resistance: the spread of resistance to antimalar-
ial drugs over the past few decades has led to an intensification of
efficacy monitoring to allow early detection of resistance in order
to revise national malaria treatment policies and ensure proper
management of clinical cases. Despite the observed changes in
parasite sensitivity to artemisinins, the clinical and parasitological
efficacy of ACTs has not yet been compromised, even in the Greater
Mekong subregion. Nonetheless, both components of the combina-
tion are currently at risk and using an ACT with an ineffective partner
medicine can increase the risk of development or spread of artemisi-
nin resistance. Similarly, if the efficacy of the artemisinin component is
lost, the efficacy of the partner drug could be jeopardized. It is noted
that 25 countries still allow the marketing of oral artemisinin-based
monotherapies that threatens the continued efficacy of artemisinin.
38 WORLD MALARIA REPORT 2010
References
1. Tracking progress in scaling-up diagnosis and treatment for malar-ia: A compilation of data on African malaria endemic countries’ estimates of their commodity needs and funding available. Gene-va, Roll Back Malaria Partnership and Medicines for Malaria Ven-ture, 2009.
2. World malaria report 2008. Geneva, World Health Organization, 2008.
3. Methods manual for laboratory quality control testing of malaria rapid diagnostic tests. Version 5a. World Health Organization.Regional Office for the Western Pacific, 2008.
4. Adeyi, O. and R. Atun, Universal access to malaria medicines: innovation in financing and delivery. Lancet, 2010, 376:1869–1871.
5. Global report on antimalarial drug efficacy and drug resistance: 2000–2010. Geneva, World Health Organization, 2010.
6. Yukich, J., et al. Cost savings with rapid diagnostic tests for malaria in low-transmission areas: Evidence from Dar es Salaam, Tanzania. The American Journal of Tropical Medicine and Hygiene, 2010, 83:61–68.
WORLD MALARIA REPORT 2010 39
Chapter 6. Impact of malaria control
This chapter considers the type of evidence that can be used
to examine whether the incidence of malaria has changed
over time and whether changes are associated with malaria
control interventions. It then summarizes the trends of
malaria cases and assesses the evidence that malaria control
activities have had an impact on malaria disease burden in
each WHO Region.
6.1 Assessing the impact of malaria interventions
6.1.1 Investigating trends in the incidence of malaria
The reported numbers of malaria cases and deaths are used as
core indicators for tracking the progress of malaria control
programmes – the working definition of a case of malaria is consid-
ered to be “fever with parasites” (1). The main sources of information
on these indicators are the disease surveillance systems operated by
ministries of health. Data from such systems have three strengths.
First, case reports are recorded continuously over time and can thus
reflect changes in the implementation of interventions or other
factors. Secondly, routine case and death reports are often available
for all geographical units of a country. Thirdly, they reflect the burden
that malaria places on the health system. Changes in the numbers of
cases and deaths reported by countries do not, however, necessarily
reflect changes in the incidence of disease in the general population,
because: (i) not all health facilities report each month, and so varia-
tions in case numbers may reflect fluctuations in the number of
health facilities reporting rather than a change in underlying disease
incidence; (ii) routine reporting systems often do not include patients
attending private clinics or morbidity treated at home, so disease
trends in health facilities may not reflect trends in the entire
community; and (iii) not all malaria cases reported are confirmed by
microscopy or RDT, so that some of the cases reported as malaria may
be other febrile illnesses (2). When reviewing data supplied by minis-
tries of health in malaria-endemic countries, the following strategy
was used to minimize the influence of these sources of error and
bias:
that malaria, and not other febrile illnesses, are tracked. For high-
burden countries in the WHO African Region, where little case
confirmation is undertaken, the numbers of malaria admissions
(inpatient cases) and deaths are reviewed because the predictive
value of diagnosis undertaken for an admitted patient is consid-
ered to be higher than outpatient diagnosis based only on clinical
signs and symptoms. In such countries, the analysis may be
heavily influenced by trends in severe malaria rather than trends
in all cases.
to measure the annual blood examination rate, which is the
number of parasitological tests (by microscopy or RDT) under-
taken per 100 people at risk per year, to ensure that potential
differences in diagnostic effort or completeness of reporting are
taken into account. To discern decreases in malaria incidence, the
annual blood examination rate should ideally remain constant or
be increased.1 In countries progressively reducing their malaria
endemicity, the population at risk also reduces, becoming limited
to residual and new foci where malaria transmission is present, or
where there is potentially a high risk due to receptivity. In addition,
it is useful to monitor the percentage of suspected malaria cases
that were examined with a parasite-based test. When reviewing
the number of malaria admissions and deaths, the health facility
reporting rate (the proportion of health facilities that report)
should remain constant and should be high, i.e. > 80%.
rate should be less severely distorted by variations in the annual
blood examination rate than trends in the number of confirmed
cases.
African countries, when the number of malaria admissions or
deaths is being reviewed, it is also informative to examine the
percentage of admissions or deaths due to malaria, as this propor-
tion is less sensitive to variation in reporting rates than the number
of malaria admissions or deaths.
system in relation to the total number of cases estimated to
occur in a country.2 Trends derived from countries with high case
detection rates are more likely to reflect trends in the broader
1. Some authorities recommend that the annual blood examination rate should exceed 10% to ensure that all febrile cases are examined; however, the observed rate depends partly on how the population at risk is estimated, and trends may still be valid if the rate is < 10%. Some authorities have noted that 10% may not be sufficient to detect all febrile cases. It is noteworthy that the annual blood examination rate in the Solomon Islands, a highly endemic country, exceeds 60%, with a slide positivity rate of 25%, achieved solely through passive case detection.
40 WORLD MALARIA REPORT 2010
community. When examining trends in the number of deaths, it is
useful to compare the total number of deaths occurring in health
facilities with the total number of deaths estimated to occur in a
country.
number of cases or deaths that cannot be explained by climate
or other factors, or inconsistency between trends in cases and in
deaths, can suggest deficiencies in reporting systems.
P. falci-
parum or the proportion of cases occurring in children < 5 years of
age. While decreases in the incidence of P. falciparum malaria may
precede decreases in P. vivax malaria, and there may be a gradual
shift in the proportion of cases occurring in children < 5 years,
unusual fluctuations in these proportions may point to changes
in health facility reporting or to errors in recording.
The aim of these procedures is to rule out data-related factors, such
as incomplete reporting or changes in diagnostic practice, as expla-
nations for a change in the incidence of disease and to ensure that
trends in health facility data reflect changes in the wider community.
The conclusion that trends inferred from health facility data reflect
changes in the community has more weight if: (i) the changes in
disease incidence are large, (ii) coverage with public health services
is high, and (iii) interventions promoting change, such as use of ITNs,
are delivered throughout the community and not restricted to health
facilities.
6.1.2 Assessing coverage with malaria interventions
Data on the number of ITNs distributed by malaria programmes
and populations covered by IRS are supplied annually by ministries
of health to WHO as part of reporting for the World Malaria Report.
Such information may contain inaccuracies or gaps, particularly for
earlier years. Hence, if data for earlier years are missing, it might be
inferred incorrectly that preventive activities have recently been
intensified. Nevertheless, for many countries, data from ministries
of health are the only source of information on preventive activities
and are consistent over the years. Data from nationally representa-
tive household surveys are available for selected countries, but these
surveys are usually not undertaken frequently enough to allow
assessment of trends in intervention coverage or to provide contem-
porary information. For sub-Saharan African countries, data from
nationally representative household surveys and information on
ITNs procured and distributed by NMCPs were combined to form an
estimate of the percentage of households owning at least one ITN in
years when household surveys were not available (Section 4.1). Infor-
mation on access to treatment is less complete than data on ITNs and
IRS, as few countries supply information on the number of courses of
antimalarial medicines distributed in relation to the number of cases
treated in the public sector. Information on preventive activities or
treatment provided by the private sector is almost entirely absent. It
is therefore not always possible to obtain a complete picture of the
extent of control activities in a country.
6.1.3 Establishing a link between malaria disease trends and control activities
In establishing a causal link between malaria disease trends and
control activities, one should consider what the disease trends would
have been without application of the control activities and then
assess whether the decrease in malaria observed is greater than that
expected without control activities. A realistic view of what would
have happened without control activities (i.e. counterfactual) cannot
be established from the data currently available; however, it can be
expected that, without a change in control activities, the malaria
incidence might fluctuate in response to short-term climate vari-
ations but would otherwise show little change, as improved living
conditions, environmental degradation or long-term climate change
have only gradual effects (although there may be local exceptions).
Thus, a plausible link with control efforts can be established if the
disease incidence decreases at the same time as control activities
increase, if the magnitude of the decrease in malaria incidence is
consistent with the magnitude of the increase in control activities (a
50% decrease in the number of cases is unlikely to occur if malaria
control activities cover only 10% of the population at risk) and if the
decreases in malaria incidence cannot readily be explained by other
factors.
Countries and territories for which there is evidence from good
quality surveillance data of a large, sustained decrease (e.g. > 50%
or > 25%) in the number of cases since 2000 are presented in Table
6.1 by WHO Region. Information on the scale of malaria control
interventions is also summarized, to identify countries with preven-
tive programmes covering > 50% of the population at high risk and
countries that undertake extensive case detection and treatment.
Countries in which there is evidence of both a sustained decrease in
cases since 2000 and extensive control activities are highlighted as
providing evidence of an impact of malaria control activities. Selected
high-burden countries in the WHO African Region are discussed indi-
vidually. For other WHO Regions, the results of the analysis are shown
in a standard set of graphs, as described in Box 6.1, section 6.3.
6.2 African Region: high burden countriesOf the 35 high-burden countries in the WHO African Region, trends
in confirmed malaria cases could be analysed in only 4 countries/areas
that have had consistent reporting on parasitologically confirmed
cases from 2000 to 2009, i.e. Eritrea, Rwanda, Sao Tome and Principe,
and Zanzibar (United Republic of Tanzania). The majority of the other
high burden countries in the Region have until recent years treated
malaria in children < 5 years of age presumptively, and only have data
on suspected malaria cases. Even if a country has increased parasito-
logical diagnosis in recent years, such as Senegal, the lack of consist-
ent historical data on confirmed cases before and after scale-up of
interventions prevents an analysis of trends.
Owing to the absence of data on confirmed cases, data on malaria
admissions and deaths were also analysed. Although in many
instances cases are not confirmed by parasitological diagnosis they
have a higher positive predictive value for malaria than outpatient
2. The World Malaria Report 2008 described methods for estimating the total number of malaria cases in a country on the basis of the number of reported cases and taking into account variations in health facility reporting rates, care-seeking behaviour for fever as recorded in household surveys and the extent to which suspected cases are examined with laboratory tests.
WORLD MALARIA REPORT 2010 41
(Fig. 6.1). The reduction in disease burden is associated with the
scale-up of malaria control efforts in the country. More than a million
ITNs were distributed over the years 2000–2006, and in 2004 about
80% of households living in areas at high risk for malaria owned a
net. The NMCP delivered another 564 000 LLINs during 2007–2009,
enough to cover 31% of the population at high risk, complement-
ed by focal IRS, protecting on average 212 000 people at high risk
per year since 2000. Enough ACTs were provided to treat all malaria
3. In recent years malaria control activities have led to reduced malaria transmission in Eritrea, Sao Tome and Principe, and Zanzibar (United Republic of Tanzania). These countries/areas may therefore be consid-ered as having low transmission. However, they are included among the high-transmission countries since they were classified as such in 2000 before they intensified malaria control activities. Their receptivity for malaria transmission remains very high (given the abundance of vectors and climate suitability) and failure to maintain the intensity of malaria control efforts could result in resurgence of malaria with major public health consequences.
Decrease in cases >50%
Decrease in cases 25-50%
Limited evidence of decrease
AFRICAN REGIONAlgeria AngolaCape Verde BeninBotswana Burkina FasoMadagascar BurundiNamibia CameroonSao Tome and Principe Central African RepublicSouth Africa ChadSwaziland CongoEritreaRwanda Democratic Rep. CongoZambia Equatorial Guinea*
Ethiopia†Gabon
Gambia*GhanaGuinea
Guinea-BissauKenya*Liberia
MalawiMali
MauritaniaMozambique
Niger
Senegal
TogoUganda
United Rep. of Tanzania*Zimbabwe
Decrease in cases >50%
Decrease in cases 25-50%
Limited evidence of decrease
REGION OF THE AMERICAS Argentina Brazil Costa RicaBelize Colombia Dominican Republic
Guyana French GuianaEcuador HaitiEl SalvadorGuatemalaHondurasMexicoNicaraguaParaguaySuriname
SOUTH-EAST ASIA REGION Bhutan BangladeshDem. People’s Rep. Korea
MyanmarSri Lanka Timor-LesteThailand
EUROPEAN REGIONAzerbaijanGeorgiaKyrgyzstan TajikistanTurkeyUzbekistan
EASTERN MEDITERRANEAN REGIONAfghanistan DjiboutiIraqIran (Islamic Rep.)Saudi Arabia Sudan*
Yemen*
WESTERN PACIFIC REGIONChina Malaysia Cambodia*Lao People’s Dem. Rep.Republic of Korea VanuatuSolomon IslandsViet Nam
Countries in bold show evidence of wide scale implementation of malaria control activities to >50% of the population at high risk. For high burden African countries Djbouti, Somalia and Sudan ITN coverage was derived from a model as described in Section 4.1
* The country reports some progress sub-nationally where interventions have been intensified.
† The number of reported cases and admissions has remained low since 2005.
suspected cases. Data were obtained from either: (i) health manage-
ment information systems (Eritrea, Sao Tome and Principe, Rwanda,
Zambia, and Zanzibar, United Republic of Tanzania3) or (ii) WHO rapid
impact assessments which examined data from outpatient records
and admissions and laboratory registers for randomly selected
district hospitals for 2000–2009 (Ethiopia and Madagascar).
ERITREA. A large reduction in the malaria burden has been
achieved in Eritrea in recent years. Although the numbers of probable
and confirmed malaria cases decreased from 126 000 in 2001 to
22 000 in 2009 (83% decrease), microscopically confirmed malaria
cases decreased by only 32% (from 9700 to 6600). This is because the
cases examined by microscopy more than doubled over this period.
The slide positivity rate fell from 43% to 8%, which may more reliably
reflect a decrease in case incidence but the rate could be influenced
by the inclusion of more cases with a lower probability of infection
as the number of cases examined increases. The number of malaria
admissions decreased from 10 900 to 4200 over the same period (61%
decrease) and reported malaria deaths from 133 to 23 (83% decrease)
TABLE 6.1
SUMMARY OF PROGRESS IN REDUCING NUMBER OF MALARIA CASES BETWEEN 2000 AND 2009
42 WORLD MALARIA REPORT 2010
patients attending public health facilities. Although progress has
been sustained since 2001 there was a small increase in confirmed
cases, admissions and deaths in 2009.
ETHIOPIA. Although a functional surveillance system exists at
the district level, aggregation of data at national level on malaria
cases and deaths from all the health facilities is often incomplete and
underestimates the true number of cases attending public health
facilities. Therefore, a review of health facility records was conducted
in all 62 hospitals located at altitudes < 2000 m (where malaria trans-
mission occurs). A total of 44 hospitals maintained adequate records
for the period 2002–2009. The numbers of malaria admissions and
deaths in the hospitals follow a similar pattern to nationally reported
data, rising to a peak in 2003 and subsequently falling (Fig. 6.2).
Given the variable levels of admissions and deaths from 2002 to 2004,
and the potential reasons for the variability, it is difficult to specify a
baseline value for the number of admissions and deaths, and hence
any percentage decrease in admissions and deaths to 2009. If the
epidemic peak of 2003 is excluded, the annual numbers of malaria
admissions and deaths for 2007–2009 are 31% and 50% lower than
values for 2002 and 2004 respectively. The lower levels of admis-
sions and deaths after 2004 are associated with an expansion in the
malaria control programme; more than 25 million ITNs were delivered
between 2005 and 2009 targeting 40 million people at high risk. The
NMCP also undertakes IRS, which has increased in scale to protect 28
million in 2008 from a base of between 2.8 and 6 million from 2002
to 2007. ACTs were made available to all public facilities in 2004 and
to community levels through health extension workers in 2007; these
workers are mandated to diagnose malaria using RDTs and to treat
confirmed malaria patients with ACTs. It is not known whether the
lower levels of hospital admissions and deaths after 2004 would have
occurred without these malaria interventions, but the major malaria
epidemics of the past seem to have been avoided in the last 5 years.
A slight increase in malaria admissions was recorded in 2009.
MADAGASCAR. The entire population of Madagascar, 19.6
million in 2009, is at some risk of malaria. About 1.4 million ITNs had
been distributed between 2001 and 2005. Malaria control activities
increased in scale from 2006 onward with 1.6 million ITNs delivered
in 2006 followed by another 2 million over the period 2007–2009.
Approximately 550 000 persons at risk were protected by IRS each
year in 2005–2007. The number increased to 1.2 million per year
in 2006 and 2007 and more than 6.5 million per year in 2008 and
2009. ACTs were adopted as policy for malaria treatment in 2006 and
provided free of charge from 2007 with more than 500 000 treatment
courses distributed in 2007 and 2008 and approximately 400 000 in
2009, sufficient to treat all patients reported to have attended public
health facilities in 2008 and 2009.
Two data sets were analysed to examine malaria trends: (i) infor-
mation from a WHO rapid impact assessment which collected data
from 45 randomly selected health facilities in high-transmission
areas and 15 in the transitional, epidemic-prone zone – of the 60
facilities, 35 had complete data for at least 8 years and were used for
analysis – and (ii) routinely reported data from the national HMIS.
Until 2006 the trend in malaria admissions followed that of non-ma-
laria admissions, but in 2007 and subsequent years it was much lower
(Fig. 6.3). Similar trends are seen in nationally reported data although
the decreases have been larger in recent years.
RWANDA. The population of Rwanda was 10 million in 2009.
During a nationwide campaign targeting children < 5 years of age
in 2006, 1.96 million LLINs were distributed, and a further 1.16 million
LLINs were distributed in 2007, increasing the percentage of the
population potentially covered by nets to 70%. No ITNs were distrib-
uted in 2008; 800 000 were delivered in 2009. The number of people
protected by IRS rose from 705 000 in 2007 to 1.4 million in 2009.
ACTs were distributed nationwide between September and October
2006, at the same time as the mass distribution of LLINs. The DHS
conducted in 2007–2008 showed that 56% of households owned an
ITN and 56% of children < 5 slept under a net.
Rwanda recorded sharp decreases in the number of confirmed
malaria cases, admissions and deaths in 2007 and for much of 2008
after the intensification of control activities (Fig. 6.4, 6.5). Towards
the end of 2008 and early 2009, however, there was a nationwide
increase in the number of confirmed malaria cases, admissions and
deaths although the increase in admissions and deaths did not
appear to be as large as that of the total number of cases. There was
a 25% increase in the number of patients tested in 2009, but this is
smaller than the 77% increase in confirmed malaria cases, and the
slide positivity rate increased from 18% in 2008 to 25% in 2009.
National-level rainfall and temperature anomalies were not associat-
ed with the resurgences4. A substantial proportion of LLINs were
distributed 2–3 years ago and it is possible that the effectiveness of
LLINs has become reduced with ageing of nets.
In response to the resurgence in uncomplicated malaria cases and
to meet the universal LLIN coverage targets, the NMCP started mass
distribution of new LLINs to selected districts according to malaria
risk mapping (two per household), providing 184 000 in December
2009 and 581 000 in March 2010. In April 2010, a further 1.6 million
new LLINs were distributed to all children < 5 years of age nationwide
during a measles vaccination campaign. As a result of these initia-
tives the resurgence in malaria cases appears to have been reversed.
From October to December 2010, another 2.1 million LLINs will be
distributed to ensure that all households have two LLINs and that
further increases in malaria cases and deaths are avoided.
SAO TOME AND PRINCIPE. The population of Sao Tome and
Principe was 165 000 in 2009. IRS protected 140 000 people in 2005,
126 000 in 2006, 117 000 in 2007 and 137 000 in 2009. No IRS was
undertaken in 2008. By 2007, nationwide ITN coverage was among
the highest in Africa: 78% of households owned at least one ITN, and
54% of children < 5 years of age slept under an ITN. ACT was intro-
duced for treatment of malaria in 2005, and the number of treatment
courses distributed in 2005–2008 was enough to cover all reported
cases.
The annual number of confirmed malaria cases in 2005–2008
was 84% lower than in 2000–2004, and in the same periods the slide
4. Data on the following climatic factors were examined: (i) Tropical Rainfall Measuring Mission (TRMM) rainfall estimates (3); (ii) satellite-based land surface temperature (LST) (4); and (iii) air temperature Climate Anomaly Monitoring System (CAMS) products (5). For each product, the average quarterly reading over the period of 2001–2008 was used to calculate a baseline, and this baseline was then used to calculate anomalies for the period 2001–2009. These anomalies were then compared with malaria case counts in each quarter by calculating Spearman rank correlations of case counts with each climatic variable in both real-time and with a one quarter lag. Additionally, multivariable regression analysis was used to simultaneously examine the effects of rainfall and temperature on malaria case increases.
WORLD MALARIA REPORT 2010 43
: Data from 44 hospitals below 2000 m. Excludes
and Dec. of each year owing to missing data in 2009
a) Admissions
a) Admissions
a) Admissions
b) Deaths
b) Deaths
b) Deaths
0
2000
4000
6000
8000
10 000
12 000
2001 2002 2003 2004 2005 2006 2007 2008 2009
Mala
ria a
dmiss
ions
0
20 000
40 000
60 000
80 000
100 000
120 000
Non
mala
ria a
dmiss
ions
Malaria admissions
Non-malaria admissions
2002 2003 2004 2005 2006 2007 2008 20090
5000
10 000
15 000
2 0000
25 000
30 000
35 000
Num
ber o
f mala
ria a
dmiss
ions
0
20 000
40 000
60 000
80 000
100 000
120 000
140 000
160 000
Num
ber o
f non
mala
ria a
dmiss
ions
Malaria admissions
Non-malaria admissions
0
1000
2000
3000
4000
5000
6000
2001 2002 2003 2004 2005 2006 2007 2008 2009
Num
ber o
f mala
ria a
dmiss
ions
0
2000
4000
6000
8000
10 000
12 000
14 000
16 000
18 000
Num
ber o
f non
mala
ria a
dmiss
ions
Malaria admissions
Non-malaria admissions
0
500
1000
1500
2000
2500
3000
2001 2002 2003 2004 2005 2006 2007 2008 2009
Mala
ria d
eath
s
0
20
40
60
80
100
120
140
Non
mala
ria d
eath
s
Non-malaria deaths
Malaria deaths
0
200
400
600
800
1000
1200
1400
1600
1800
2002 2003 2004 2005 2006 2007 2008 2009
Mala
ria d
eath
s
0
1000
2000
3000
4000
5000
6000
7000
8000
Non-
mala
ria d
eath
s
Malaria deaths
Non-malaria deaths
0
50
100
150
200
250
300
350
400
450
2001 2002 2003 2004 2005 2006 2007 2008 2009
Num
ber o
f mala
ria d
eath
s
0
200
400
600
800
1000
1200
1400
Num
ber o
f non
mala
ria d
eath
s
Malaria deaths
Non-malaria deaths
Figure 6.1 Malaria and non malaria admissions and deaths in Eritrea, 2001–2009
Figure 6.2 Malaria and non malaria admissions and deaths in Ethiopia, 2002–2009
Figure 6.4 Confirmed malaria cases and slide positivity rate, Rwanda, 2001–2010
Figure 6.5 Malaria admissions and deaths, Rwanda, 2000–2010
Figure 6.3 Malaria and non malaria admissions and deaths in Madagascar, 2001–2009
0
20
40
60
80
100
120
2001 2002 2003 2004 2005 2006 2007 2008 2009 20100
10
20
30
40
50
60
70
80Confirmed cases
Num
ber o
f con
firm
ed ca
ses (
in th
ousa
nds)
Slide
pos
itivit
y rat
e (%
)
Slide positivity rate
0
1000
2000
3000
4000
5000
6000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Num
ber o
f mal
aria
adm
issio
ns
0
50
100
150
200
250
300
Num
ber o
f mala
ria d
eath
s
Admissions
Deaths
44 WORLD MALARIA REPORT 2010
positivity rate fell from 47% to less than 13% (Fig. 6.6). The annual
number of admissions due to malaria was 87% lower in 2005–2008
than in 2000–2004, while the percentage of admissions for malaria
fell from an average of 62% in 2000–2004 to 23% in 2005–2008.
Similarly, the number of malaria reported deaths in 2005–2008 was
86% lower than in 2000–2004, and the percentage of deaths due to
malaria in health facilities fell from 23% to 4%.
Until 2008, the data show a strong association between inter-
ventions and impact (5). However, in 2009 the number of confirmed
malaria cases increased from 1647 to 3893, a 140% increase since
2008. Malaria-related admissions rose from 850 to 950 (up 44%) and
malaria-related deaths from 16 to 23 (up 44%). The increase in 2009
followed a year when IRS had not been carried out, although the
percentage of households owning at least one ITN remained high
in 2009 (76% from a national survey). Once the increase in cases was
detected by the surveillance system, emergency IRS was implement-
ed and malaria cases decreased during the second half of 2009.5
ZAMBIA. Between 2001 and 2008 the number of admissions and
deaths due to malaria had shown a consistent decrease (Fig. 6.7),
which was associated with increased malaria control activities (World
Malaria Report 2009). The magnitude of the decrease observed in
health facility data was similar to changes observed in household
survey data. For example, the numbers of malaria admissions and
deaths among children < 5 years of age decreased by 57% and 62%,
respectively, while the number of admissions for anaemia decreased
by 47%. Parasite prevalence among children < 5 decreased by 53%
between 2006 and 2008 (from 21.8% to 10.2%), and the percentage
of children with severe anaemia (< 8 g/dl haemoglobin) decreased
5. Lee et al. Potential threat of malaria epidemics in a low transmission area, as exemplified by São Tomé and Príncipe. Malaria Journal 2010, 9:264. http://www.malariajournal.com/content/9/1/264
by 68% (from 13.3% to 4.3%). The consistency of trends between
data sources suggested that the decreases were real and that health
facility data could provide reliable information on changes in malaria
incidence and mortality.
In 2009 the downward trend in malaria admissions and deaths
levelled off nationally but there were small increases in malaria
admissions in 5 of 9 provinces and a major resurgence in Eastern and
Luapula provinces, where malaria admissions more than doubled
when compared with 2008 numbers (Fig. 6.8). The change in malaria
admissions has been paralleled by changes in parasite prevalence in
children < 5 as measured by malaria indicator surveys undertaken in
2006, 2008 and 2010 (6,7,8) (Fig. 6.9). In Eastern province, parasite
prevalence dropped from 22.8% in 2006 to 9.3% in 2008 but rose to
22.6% in 2010. In Luapula province, parasite prevalence decreased
from 37.5% in 2006 to 21.8% in 2008, but rose to 53.5% in 2010. In
other provinces the rise in parasite prevalence is less pronounced.
The surveys in both provinces were conducted in May during each of
the 3 years.
Household ITN ownership declined from 69.8% in 2008 to 50% in
2010 in Luapula province, but remained relatively high in Eastern
province (74.8% in 2008 and 76.1% in 2010), so decreasing ITN
coverage does not account for the malaria resurgence observed in
both provinces. A large proportion of nets were delivered 2–3 years
before the resurgence and it is possible that their effectiveness has
deteriorated owing to decay of insecticide and physical deterioration
of nets. Rainfall increased in both provinces in the quarter prior to the
resurgence. The impact of malaria control on malaria admissions,
cases and deaths was less in Luapula and Eastern provinces than in
other provinces before the resurgence.
a) Admissions
a) Admissions
b) Deaths
b) Deaths
02000
40006000
800010 000
12 00014 000
16 00018 000
Mala
ria a
dmiss
ions
0
2000
4000
6000
8000
10 000
12 000
Non
mala
ria a
dmiss
ions
Malaria admissionsNon-malaria admissions
20012000 2002 2003 2004 2005 2006 2007 2008 2009
0
50 000
100 000
150 000
200 000
250 000
300 000
350 000
400 000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Mala
ria a
dmiss
ions
0
100 000
200 000
300 000
400 000
500 000
600 000
Non
mala
ria a
dmiss
ions
Malaria admissions
Non-malaria admissions
20012000 2002 2003 2004 2005 2006 2007 2008 20090
50
100
150
200
250
300
350
Mala
ria d
eath
s
0
200
400
600
800
1000
1200
Non
mala
ria d
eath
sMalaria deaths
Non-malaria deaths
0
5000
10 000
15 000
20 000
25 000
30 000
35 000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Mala
ria d
eath
s
010002000300040005000600070008000900010 000
Non
mala
ria d
eath
s
Non-malaria deaths
Malaria deaths
Figure 6.6 Malaria and non-malaria admissions and deaths in Sao Tome and Principe, 2000–2009
Figure 6.7 Malaria and non-malaria admissions and deaths in Zambia, 2000–2009
WORLD MALARIA REPORT 2010 45
2001 2002 2003 2004 2005 2006 2007 2008 20090
5000
10000
15000
20000
25000
30000
Inpa
tient
mala
ria ca
ses,
<5
year
s old
Central Province
CopperbeltProvince
Lusaka Province
North WesternProvince
Northern Province
Southern Province
Western Province
a) Eastern and Luapula Provinces
a) Admissions
b) Other provinces
b) Deaths
2001 2002 2003 2004 2005 2006 2007 2008 20090
5000
10 000
15 000
20 000
25 000
30 000
Inpa
tient
mala
ria ca
ses,
<5
year
s old
Eastern Province
Luapula Province
0
2000
4000
6000
8000
10 000
12 000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Mala
ria a
dmiss
ions
0
2000
4000
6000
8000
10 000
12 000
14 000
16 000
18 000
20 000
Non
mala
ria a
dmiss
ions
Malaria admissions
Non-malaria admissions
0
50
100
150
200
250
300
350
400
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Mala
ria d
eath
s
0
50
100
150
200
250
300
350
400
450
Non
mala
ria d
eath
s
Non-malaria deaths
Malaria deaths
Figure 6.8 Malaria admissions <5 years of age, Zambia, 2001–2009 by province
Figure 6.10 Malaria and non-malaria admissions and deaths in Zanzibar, United Republic of Tanzania 2000–2009
Figure 6.9 Parasite prevalence in children <5 years of age, Zambia 2006, 2008, and 2010
0
10
20
30
40
50
Para
site p
reva
lence
(%)
2006
20082010
CentralProvince
CopperbeltProvince
SouthernProvince
Western Province
LusakaProvince
North WesternProvince
NorthernProvince
EasternProvince
LuapulaProvince
Zambia, all Provinces
ZANZIBAR, UNITED REPUBLIC OF TANZANIA. The islands of
Zanzibar (UR Tanzania) had a population of 1.3 million in 2009. ACTs
have been made freely available in all public health facilities since
September 2003. Approximately 245 000 LLINs were distributed in
2006, enough to cover 40% of the population, and a further 502 000
were distributed in 2007–2009, enough to cover the entire popula-
tion. IRS has been carried out annually since 2006 with each round
covering nearly all households.
The numbers of malaria admissions and deaths decreased
substantially between 2003 and 2009. In 2007–2009, the numbers of
malaria admissions and deaths were 81% lower than those recorded
in 2000–2002 (Fig. 6.10). In contrast the number of admissions for
conditions other than malaria was 21% higher. The numbers of
malaria deaths recorded in 2007–2009 were 90% lower than in
2000–2002 while deaths from conditions other than malaria were
just 7% lower.
The dramatic decrease in the number of admissions for malaria in
Zanzibar was associated with high coverage of antimalarial interven-
tions. The decrease could also be due in part to improved diagnosis
of cases as RDTs began to be more widely used from 2005. Other
evidence for an impact of malaria interventions comes from a detailed
investigation in one district, where among children < 5 years there
were substantial reductions in P. falciparum prevalence, malaria-re-
lated admissions, blood transfusions, crude mortality and malaria-
attributed mortality following the introduction of ACTs in 2003 (6).
46 WORLD MALARIA REPORT 2010
6.3 African Region: low-transmission countries Of the countries in the African Region that are considered to
have low levels of malaria transmission, Algeria is in the elimination
phase and recorded only 93 indigenous cases between 2000 and
2009. In Botswana, Cape Verde, Namibia, South Africa, Swaziland and
Zimbabwe, malaria is highly seasonal, and transmission is of much
lower intensity than in the rest of sub-Saharan Africa. The vast majority
of cases are due to P. falciparum (Fig. 6.11b). Five countries (Botswana,
Cape Verde, Namibia, South Africa and Swaziland) recorded sustained
decreases of more than 50% in the numbers of confirmed cases
between 2000 and 2009 (Fig. 6.11e). Four of these countries also
reported decreases in the number deaths due to malaria (Table 6.2).
Cape Verde moved into the pre-elimination phase in 2010. In Zimbabwe,
the number of confirmed malaria cases has fluctuated between
16 000 and 117 000 between 2004 and 2009, partly because of changes
in the number of cases examined by microscopy. It is therefore not
possible to identify any trends in malaria incidence in Zimbabwe.
There was a large decrease in the number of recorded malaria deaths
in Zimbabwe between 2002 and 2009, while the total number of
deaths reported from all causes appears to have increased over this
time.
The scale of IRS has remained fairly constant over the past 8 years;
Botswana, Namibia, South Africa and Swaziland protected more
than 70% of their populations at risk per year during 2007–2009.
Zimbabwe has also increased the proportion of the population at
risk protected by IRS to more than 60% in 2009. These countries have
deployed sufficient courses of ACTs to treat all patients attending
public health facilities.
In summary, 4 of the 5 low-transmission countries in southern
Africa (Botswana, Namibia, South Africa and Swaziland) showed
more than 50% decreases in the numbers of malaria cases between
2000 and 2009. Cape Verde also showed sustained decreases from
2000 to 2008 enabling it to enter the pre-elimination phase of
malaria control. It recorded a rise in cases in 2009 which was princi-
pally due to increased case detection efforts. All of these countries
implemented malaria interventions on a large scale. It is not possible
to determine whether the number of cases in Zimbabwe is increas-
ing, stable or decreasing, but preventive activities appeared to cover
more than 50% of the population at high risk in 2008, and the number
of malaria-related deaths has dropped substantially.
Botswana Cape Verde Namibia South Africa Swaziland Zimbabwe2000 4242001 29 0 1728 81 622002 23 2 1504 96 46 18442003 18 4 1106 142 30 10442004 19 4 1185 88 28 18092005 11 2 1325 63 17 19162006 40 7 571 87 27 8022007 6 2 181 37 17 4012008 12 2 171 43 10 2322009 6 2 46 45 13 14
BOX 6.1
EXPLANATION OF GRAPHS
Population at risk: population at high risk for malaria is that living in areas where the incidence is more than 1 per 1000 per year (defined at the second or lower administrative level). The population at low risk for malaria is that living in areas with less than 1 case of malaria per 1000 per year (see technical notes).
Percentage of cases due to P. falciparum: percentage of confirmed cases in which P. falciparum or a mixed infection was detected.
Annual blood examination rate: number of slide examinations carried out each year in relation to the population at risk for malaria, expressed as a percentage (see technical notes).
Confirmed cases reported as a percentage of total estimated: total number of confirmed cases in relation to the estimated number of malaria cases in a country. The estimated number of cases is calculated by taking into account: (i) the completeness of reporting from health facilities, (ii) the extent to which people with fever use public health facilities for treatment, and (iii) the extent to which public health facilities undertake case confirmation (see technical notes). The width of the bars reflects uncertainty around the estimate of the number of cases.
Change in number of reported cases: the number of confirmed malaria cases is shown on the vertical axis, with each country indexed at 100 in 2000 (or a later year if data were not available for 2000); i.e. a value of 200 in 2005 indicates that the number of cases in 2005 was twice that reported in 2000 and represents a 100% increase. Countries with evidence of a decrease are generally those in which there has been a consistent decrease in the number of cases and consistency in reporting of malaria cases (e.g. stable annual blood examination rate). Countries for which there is little evidence of a decrease are those that do not show a decrease in the number of cases or where there have been irregular variations in surveillance data (e.g. annual blood examination rate falling, or unexplained variations in the percentage of cases due to P. falciparum).
IRS and ITNs delivered: the vertical scale shows the percentage of the population at risk for malaria potentially covered by preventive programmes with IRS and ITNs. It is assumed that each net delivered can cover two people, that conventional nets are re-treated regularly, and that each net is not replaced before 3 years. It is also assumed that IRS and ITNs target different populations. The percentage of the population potentially covered is therefore the maximum possible covered by the interventions delivered. The denominator is the population living at high risk for malaria, as the number of malaria cases in areas of low risk is small. The scale of preventive efforts in any year is calculated as: 100 x (number of ITNs delivered in past 3 years + number of people protected by IRS in current year) ÷ population at high risk. Note that this indicator can exceed 100% if interventions are also applied to populations at low risk or if some high-risk populations are covered both by ITNs and IRS.
TABLE 6.2
NUMBER OF MALARIA DEATHS reported by low transmission countries, 2000–2009
WORLD MALARIA REPORT 2010 47
Figure 6.11 WHO African Region – low transmission countries
d) Confirmed cases as a percentage of total estimated cases, 2009
e) Changes in numbers of confirmed cases, 2000–2009: countries with evidence of sustained decrease in cases
b) Percentage of cases due to P. falciparum, 2009a) Population at risk, 2009
f) Changes in numbers of confirmed cases, 2000–2009: countries with limited evidence of sustained decrease in cases
c) Annual blood examination rate, average 2000–2009
g) IRS and ITNs delivered – maximum percentage of high risk population protected: countries with evidence of sustained decrease in cases
h) IRS and ITNs delivered – maximum percentage of high risk population potentially covered: countries with limited evidence of sustained decrease
0
50
100
150
200
250
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Cape Verde
South Africa
Swaziland
Botswana
Namibia Zimbabwe
0
50
100
150
200
250
300
350
400
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
0%
50%
100%
150%
200%
250%
300%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Namibia
South Africa
Swaziland
Botswana
High risk Low risk Malaria free
0% 20% 40% 60% 80% 100%
Algeria
South Africa
Cape Verde
Swaziland
Zimbabwe
Botswana
Namibia
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Zimbabwe
Swaziland
South Africa
Namibia
Cape Verde
Botswana
Algeria
0% 10% 20% 30% 40% 50%
Namibia
South Africa
Algeria
Botswana
Zimbabwe
Swaziland
Cape Verde
0%
50%
100%
150%
200%
250%
300%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Zimbabwe
0% 10% 20% 30% 40% 50% 60% 70%
Namibia
Zimbabwe
Swaziland
Cape Verde
Botswana
South Africa
48 WORLD MALARIA REPORT 2010
ECUADOR. Confirmed malaria cases decreased from 105 000 in 2000 to 4120 in 2009, a reduction of 96%. The proportion of cases due to P. falciparum also decreased from 47% in 2000 to 13% in 2009. Today, only 4% of the 13.8 million population are at high risk for malaria (living in areas where incidence exceeds 1 case per 1000 per year). IRS has been the principal vector control method, covering an average of 344 500 people at risk per year in 2007–2009. The NMCP also distributed 458 000 LLINs free of charge in 2008–2009. These two interventions are sufficient to cover more than 100% of the population at high risk. Malaria diagnosis and treatment are provided free of charge for all age groups in the public sector; ACTs have been available for the treatment of P. falciparum malaria since 2005. Ecuador was awarded US$ 6.9 million from the Global Fund for Phase I of a project commencing in 2009. It also receives funds from UNICEF (US$ 80 000, 2009) and USAID (US$ 200 000, 2007–2008). The government has traditionally provided the majority of funding for malaria control (US$ 2.4 million in 2009), indicating strong national commitment to malaria control.
6.4 Region of the AmericasMalaria transmission occurs in 23 countries and territories of the
WHO Region of the Americas, with almost 20% of the total popula-
tion at some degree of risk. Four of these countries (Argentina, El
Salvador, Mexico, and Paraguay) are now in the elimination or pre-
elimination phase; 2 countries (Bahamas, Jamaica) are preventing
reintroduction of malaria after local outbreaks subsequent to impor-
tation of parasites.
Overall, P. vivax accounted for 80% of all cases reported in 2009,
but the percentage of cases due to P. falciparum was almost 100% in
the Dominican Republic and Haiti (Fig. 6.12b). Reported cases in the
Region decreased from 1.18 million in 2000 to 526 000 in 2009. Four
countries (Brazil, Colombia, Haiti and Peru) accounted for 90% of the
cases in 2009. Reductions of more than 50% in the number of reported
cases between 2000 and 2009 were seen in 11 countries (Argentina,
Belize, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua,
Paraguay, Plurinational State of Bolivia, and Suriname) (Fig. 6.12e).
Three countries (Brazil, Colombia and Guyana) had smaller reduc-
tions (25%–50%) in the number of confirmed malaria cases between
Num
ber o
f con
firm
ed m
alaria
case
s
Cove
rage
ABE
R (%
)
0
20 000
40 000
60 000
80 000
100 000
120 000
2000 2001 2002 2003 2004 2005 2006 2007 2008 20090
20
40
60
80
100Maximum coverage (IRS and ITNs)Confirmed casesAnnual blood examination rate (ABER)
Figure Box 6.2 Trends in cases and malaria programme coverage, 2000–2009
a) Ecuador b) Suriname
2000 and 2009; Guyana registered a small increase in 2009 compared
to 2008.
In 4 countries the scale of preventive activities is sufficient to cover
50% or more of the population at high risk (Ecuador, Guatemala,
Nicaragua and Suriname). Brazil has greatly extended the availability
of diagnosis and treatment through a network of more than 40 000
health workers who reach individual households.
The number of confirmed cases in French Guiana showed little
change between 2000 and 2008 (no data were reported in 2009).
Three countries (the Bolivarian Republic of Venezuela, the Dominican
Republic, and Haiti) reported increased numbers of cases between
2000 and 2009, with the highest increase seen in Haiti (3 times more
cases in 2009 compared to 2000). The risk of malaria may have further
increased in Haiti in 2010 as a result of the earthquake in January and
widespread use of temporary housing, although the risk will also
depend on climatic conditions.
In summary, 9 countries, Argentina, Belize, Ecuador, El Salvador,
Guatemala, Mexico, Nicaragua, Paraguay, and Suriname, experienced
a decrease in the number of cases of more than 50%, associated with
intense malaria programme activity.
SURINAME. The number of confirmed malaria cases peaked in 2001 at 16 000 and has fallen steadily to 1700 in 2009, a 90% decrease. The number of reported malaria deaths fell from 24 in 2000 to zero in 2009, while the proportion of cases due to P. falciparum decreased from 84% to 22% in the same period. Today, only 11% of the 524 000 population is at risk of malaria. The annual blood examination rate was 54% in 2009 reflecting intensive efforts at case detection; the rate had been higher than 100% earlier in the decade, probably due to the high number of migrants from neighbouring countries treated in Suriname. The NMCP distributed 22 500 LLINs in 2007–2009, enough to cover 78% of the population at risk. IRS was also implemented selectively in focal areas. Suriname has benefited from substantial external funding for malaria control with US$ 4.5 million disbursed from Global Fund grants between 2006 and 2009.
Num
ber o
f con
firm
ed m
alaria
case
s
Cove
rage
ABE
R (%
)
Maximum coverage (IRS and ITNs)Confirmed casesAnnual blood examination rate (ABER)
0
2000
4000
6000
8000
10 000
12 000
14 000
16 000
18 000
2000 2001 2002 2003 2004 2005 2006 2007 2008 20090
20
40
60
80
100
120
140
BOX 6.2
EXAMPLES OF SUCCESSFUL MALARIA CONTROL IN THE AMERICAS
WORLD MALARIA REPORT 2010 49
Figure 6.12 WHO Region of the Americas
d) Confirmed cases as a percentage of total estimated cases, 2009
e) Changes in numbers of confirmed cases, 2000–2009: countries with evidence of sustained decrease in cases
b) Percentage of cases due to P. falciparum, 2009a) Population at risk, 2009
f) Changes in numbers of confirmed cases, 2000–2009: countries with limited evidence of sustained decrease in cases
c) Annual blood examination rate, average 2000–2009
h) IRS and ITNs delivered – maximum percentage of high risk population potentially covered: countries with limited evidence of sustained decrease
0
20
40
60
80
100
120
140
160
180
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Argentina
Belize
Bolivia (Pluri. State)Brazil
Colombia
EcuadorEl Salvador
Guatemala
GuyanaHonduras
Mexico
Nicaragua
Paraguay
Suriname
0
100
200
300
400
500
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Costa Rica
PeruVenezuela (Bolivarian Rep.)French Guiana
Dominican Republic
Haiti
0%
50%
100%
150%
200%
250%
300%
2002 2003 2004 2005 2006 2007 2008 2009
Bolivia (Pluri. State)
Brazil
Colombia
Ecuador
El Salvador
Argentina
Nicaragua
Mexico
Guyana
0% 20% 40% 60% 80% 100%Mexico
ArgentinaSurinameColombia
BrazilVenezuela (Boliv. Rep.)
Costa RicaHonduras
PeruEcuador
BelizeParaguay
GuatemalaDominican RepublicBolivia (Pluri. State)
El SalvadorNicaragua
GuyanaPanama
HaitiFrench Guiana
High risk Low risk Malaria free
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ArgentinaBelize
MexicoCosta Rica
PanamaGuatemalaEl Salvador
BoliviaPeru
ParaguayEcuador
VenezuelaHonduras
NicaraguaBrazil
ColombiaSuriname
GuyanaFrench Guiana
JamaicaBahamas
Dominican Rep.Haiti
0% 10% 20% 30% 40% 50%
139%
ArgentinaGuatemala
Bolivia (Pluri. State)Paraguay
Costa RicaEl Salvador
Dominican RepublicBrazil
PanamaHonduras
Venezuela (Boliv. Rep.)ColombiaEcuador
NicaraguaBelize
PeruHaiti
French GuianaGuyanaMexico
Suriname
0%
50%
100%
150%
200%
250%
300%
2002 2003 2004 2005 2006 2007 2008 2009
French Guiana
Panama
Dominican Republic
Haiti
g) IRS and ITNs delivered – maximum percentage of high risk population protected: countries with evidence of
sustained decrease in cases
0% 20% 40% 60% 80% 100%Haiti
GuatemalaHonduras
Dominican RepublicPeru
Costa RicaVenezuela (Bolivarian Rep.)
ColombiaFrench Guiana
SurinameGuyana
NicaraguaEcuador
Bolivia (Pluri. State)Panama
ParaguayBrazil
ArgentinaBelize
El SalvadorMexico
50 WORLD MALARIA REPORT 2010
BHUTAN. Approximately 74% (493 000) of the total population (688 000) is at risk of malaria. Malaria occurs primarily in 15 districts that border India. The number of confirmed malaria cases has fallen from 5982 in 2000 to 972 in 2009, a decrease of 84%. In 2009, 58% of cases were due to P. falciparum. Only 4 malaria deaths were reported in 2009. An average of 145 000 people were protected each year with IRS in 2004–2009, and 132 000 ITNs were distributed. A household survey conducted in malaria endemic districts in 2009 indicated that 94% of households owned at least one ITN. ACTs were adopted for treatment of P. falciparum malaria in 2005 and are made available through public sector health facilities free of charge; there are few private sector treatment facilities in Bhutan. Government financing for malaria control averaged US$ 225 000 per year in 2005–2009. Over the same period disbursements from the Global Fund averaged US$ 600 000 per year and contributions from UN agencies and bilateral donors averaged US$ 204 000.
SRI LANKA. The number of confirmed malaria cases decreased from 210 000 in 2000 to 558 in 2009 and the proportion of cases due to P. falciparum from 28% to 5%. The number of reported deaths fell from 77 in 2000 to zero in 2009. A key strategy to reduce malaria cases has been the use of Malaria Mobile Clinics (MMCs) comprising at least 3 health personnel and a 4-wheel-drive vehicle to make services available to populations that do not have access to health facilities. Diagnosis was initially confirmed by trained microscopists but microscopy was supplemented with RDTs when MMCs were extended to areas lacking trained microscopists. IRS had been the principal method of vector control with an average of 50% of the population at risk protected in 2001–2004. ITNs were introduced as a complementary measure for populations at high risk. Government expenditures for malaria averaged US$ 1.6 million per year in 2005–2009 while disbursements from the Global Fund averaged US$ 2.4 million over the same period. The country is now in the pre-elimination phase of malaria control.
6.5 South-East Asia RegionOf the 11 countries in the WHO South-East Asia Region, 10 are
malaria-endemic; there has been no indigenous transmission of
malaria in the Maldives since 1984. Approximately 60% of the total
population in the Region is at some risk of malaria, with 20% at high
risk (in areas with a reported incidence of more than 1 case per 1000
population per year). In 2009, 2.4 million parasitologically confirmed
malaria cases and 3320 deaths were reported, a 7% decrease in cases
since 2000. Three countries accounted for 94% of the reported cases
in the Region in 2008 (India, 65%, Myanmar, 20% and Indonesia,
12%). Most cases in the Region are due to P. falciparum, although the
proportion varies by country; transmission is due almost entirely to P.
falciparum in Myanmar and Timor-Leste but exclusively to P. vivax in
the Democratic People’s Republic of Korea (Fig. 6.13b). Reductions of
more than 50% in the number of reported cases in 2000–2009 were
recorded in 5 countries (Bhutan, the Democratic People’s Republic
of Korea, Nepal, Sri Lanka and Thailand; Fig. 6.13e). The number of
confirmed cases in India was 23% lower in 2009 than in 2000. There
was evidence of widespread implementation of anti-malarial inter-
ventions in 3 countries that showed decreases in the number of cases
(Bhutan, Sri Lanka and Thailand), although intervention coverage has
been less than 50% in recent years in Sri Lanka and Thailand. Two
countries in the pre-elimination stage actively follow up all suspected
cases (Democratic People’s Republic of Korea and Sri Lanka). The
scale of preventive interventions appears to be limited in India and
Nepal, with coverage of less than 30% of the population at high risk.
The remaining malaria-endemic countries reported either no
change or an increase in the number of cases (Bangladesh, Indonesia,
Myanmar and Timor-Leste), and the scale of control activities
appeared to be small in relation to the total population at risk.
Confirmed malaria cases in Myanmar increased by more than 16-fold
between 2000 and 2009, due primarily to the increased availability of
parasitological diagnosis by both microscopy and RDTs.
In summary, 4 countries (Bhutan, the Democratic People’s
Republic of Korea, Sri Lanka and Thailand) experienced a decrease in
the number of malaria cases of more than 50% since 2000, associated
with intensive malaria programme activity.
Figure Box 6.3 Trends in cases and malaria programme coverage, 2000–2009
Num
ber o
f con
firm
ed m
alaria
case
s
Cove
rage
ABE
R (%
)
Maximum coverage (IRS and ITNs)Confirmed casesAnnual blood examination rate (ABER)
0
1000
2000
3000
4000
5000
6000
7000
2000 2001 2002 2003 2004 2005 2006 2007 2008 20090
20
40
60
80
100
a) Bhutan b) Sri Lanka
Num
ber o
f con
firm
ed m
alaria
case
s
Cove
rage
ABE
R (%
)
Maximum coverage (IRS and ITNs)Confirmed casesAnnual blood examination rate (ABER)
0
50 000
100 000
150 000
200 000
250 000
2000 2001 2002 2003 2004 2005 2006 2007 2008 20090
20
40
60
80
100
BOX 6.3
EXAMPLES OF SUCCESSFUL MALARIA CONTROL IN THE SOUTH-EAST ASIAN REGION
WORLD MALARIA REPORT 2010 51
Figure 6.13 WHO South-East Asia Region
d) Confirmed cases as a percentage of total estimated cases, 2009
e) Changes in numbers of confirmed cases, 2000–2009 countries with evidence of sustained decrease in cases
b) Percentage of cases due to P. falciparum, 2009a) Population at risk, 2009
f) Changes in numbers of confirmed cases, 2000–2009: countries with limited evidence of sustained decrease in cases
c) Annual blood examination rate, average 2000–2009
h) IRS and ITNs delivered – maximum percentage of high risk population protected: countries with limited evidence of sustained decrease in cases
0
50
100
150
200
250
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Bhutan
Democratic People's Republic of KoreaIndiaNepal
Sri Lanka
Thailand
Indonesia
Myanmar
Timor-Leste
0
50
100
150
200
250
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Bangladesh
0
100
200
300
400
500
2002 2003 2004 2005 2006 2007 2008 2009
Dem. People's Rep. of Korea
Bhutan
NepalSri LankaThailand
High risk Low risk Malaria free
0% 20% 40% 60% 80% 100%
Sri Lanka
Bangladesh
Thailand
Dem.People's Rep. of Korea
Bhutan
Nepal
India
Indonesia
Myanmar
Timor-Leste
0% 20% 40% 60% 80% 100%
Dem. People's Rep. of Korea
Sri Lanka
Nepal
Thailand
Indonesia
India
Bhutan
Timor-Leste
Bangladesh
Myanmar
0% 10% 20% 30% 40% 50%
Bangladesh
Nepal
Dem. People's Rep. Korea
Myanmar
Indonesia
India
Timor-Leste
Thailand
Bhutan
Sri Lanka
g) IRS and ITNs delivered – maximum percentage of high risk population protected: countries with evidence of sustained decrease in cases
0
20
40
60
80
100
2002 2003 2004 2005 2006 2007 2008 2009
Indonesia
Bangladesh
India
Myanmar
Timor-Leste
0% 20% 40% 60% 80% 100%
DPR Korea
Myanmar
India
Bangladesh
Indonesia
Timor-Leste
Thailand
Sri Lanka
Nepal
Bhutan
52 WORLD MALARIA REPORT 2010
6.6 European RegionIndigenous malaria cases were reported in 5 countries in the WHO
European Region in 2009: Azerbaijan, Georgia, Kyrgyzstan, Tajikistan
and Turkey. Armenia and Turkmenistan continue to report zero local-
ly-acquired cases and Turkmenistan was certified as malaria-free
in October 2010. Uzbekistan reported zero local cases for the first
time in 2009 while Tajikistan reported zero locally-acquired P. falci-
parum cases in 2009. Thus in 2009 all locally-acquired cases in the
Region were due to P. vivax. Overall, the number of indigenous cases
reported in the Region decreased from 32 385 in 2000 to 285 in 2009.
All countries registered a decrease of more than 90% in the number
of cases since 2000 except Kyrgyzstan that had a 67% reduction with
only 4 cases in 2009, after a peak of 2744 cases in 2002 (Fig. 6.14e).
IRS is the primary means of vector control in all countries, applied
with strict total coverage of all residual and new foci of malaria,
aimed at interrupting transmission over the target area as soon
as possible and preventing its re-establishment. The intensity of
activity is evident in all of the countries – more than 80% coverage
of preventive interventions in populations at high risk and more than
Cross-border collaboration is of special importance in the context of malaria elimination, where there is a risk of spread of malaria between countries and neighbouring regions. Over 1 million people live in districts on the Azerbaijan–Georgia border, including over 600 000 in 7 districts in Azerbaijan and 416 000 in 6 districts in Georgia. There are close political, economic and cultural ties between the countries with ethnic Azerbaijanis living in Georgia and ethnic Georgians living in Azerbaijan and frequent population movements across the border. Azerbaijan and Georgia both made a commitment to eliminate malaria by endorsing the Tashkent Declaration in December 2005. In 2008 both countries developed National Malaria Elimination Strategies and shifted national malaria programmes from control to elimination.
2004 2006
2008
2005
2007 2009
Figure Box 6.4 Distribution of malaria in Armenia, Azerbaijan and Georgia, 2004–2009
The first meeting on inter-country coordination on malaria elimination between Azerbaijan and Georgia was held in Baku on 19 March 2009, under the auspices of EURO. The meeting resulted in a Joint Statement on inter-country cooperation on malaria elimination in Azerbaijan and Georgia. The parties to the Joint Statement agreed to ensure regular exchange of information, synchronize action plans, ensure early notification of any changes, establish a joint working group, appoint focal points in each country, coordinate mobilization of additional resources, and take actions to create greater awareness of the successes of malaria elimination programmes. Joint activities started in May 2010 including IRS programmes in border areas.
20% annual blood examination rate (Fig. 6.14c,g). ITNs are used as a
supplementary intervention, particularly in Tajikistan. All suspected
cases are examined by microscopy and all confirmed cases are
treated; information on their origins is traced for further epidemio-
logical classification of malaria foci.
Countries make concerted efforts to prevent the spread of malaria
across neighbouring country borders. In 2005, all 9 malaria-affected
countries in the Region at that time (including the Russian Federa-
tion) endorsed the Tashkent Declaration (9), the goal of which is to
interrupt malaria transmission by 2015 and eliminate the disease
in the Region. Since 2008, national and inter-country strategies on
malaria have been revised to address cross-border collaboration and
other new challenges for malaria elimination.
In summary, 5 of the 6 endemic countries reported local cases in
2009, all with sustained decreases of more than 50% in the number
of cases since 2000. No indigenous P. falciparum cases were reported
in 2009, for the first time since the resurgence of malaria in the early
1990s. All malaria-endemic countries in the Region have active
control programmes.
BOX 6.4
CROSS-BORDER COLLABORATION ON MALARIA ELIMINATION: AZERBAIJAN – GEORGIA
WORLD MALARIA REPORT 2010 53
Figure 6.14 WHO European Region
d) Confirmed cases as a percentage of total estimated cases, 2009
e) Changes in numbers of confirmed cases, 2000–2009: countries with evidence of sustained decrease in cases
b) Percentage of cases due to P. falciparum, 2009a) Population at risk, 2009
c) Annual blood examination rate, average 2000–2009
20
60
100
140
180
220
260
300
-20 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Russian Federation
Georgia
Kyrgyzstan
Azerbaijan
Tajikistan
Uzbekistan
Turkey
0
100
200
300
400
500
2002 2003 2004 2005 2006 2007 2008 2009
Georgia Kyrgyzstan Armenia Turkmenistan
Azerbaijan Tajikistan Turkey Uzbekistan
High risk Low risk Malaria free
0% 20% 40% 60% 80% 100%
Armenia
Azerbaijan
Georgia
Kyrgyzstan
Turkey
Turkmenistan
Uzbekistan
Tajikistan
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Armenia
Azerbaijan
Georgia
Kyrgyzstan
Turkey
Turkmenistan
Uzbekistan
Tajikistan
0% 10% 20% 30% 40% 50%
Azerbaijan
Georgia
Turkey
Turkmenistan
Uzbekistan
Tajikistan
Kyrgyzstan
g) IRS and ITNs delivered – maximum percentage of high risk population protected: countries with evidence of sustained decrease in cases
0% 20% 40% 60% 80% 100%
Georgia
Turkey
Tajikistan
Azerbaijan
Kyrgyzstan
54 WORLD MALARIA REPORT 2010
Recorded malaria in Morocco peaked at more than 350 000 cases in 1939 and remained high until 1947 when 303 000 cases and 548 deaths were reported. Since then the malaria burden has declined steadily in response to a combination of intensified control interventions, improved health service coverage and socio-economic development. Malaria has been a notifiable disease since 1967. Malaria due to P. falciparum was the first to disappear, with the last local case recorded in 1974, but transmission of P. vivax continued at low levels. In 1999, the Ministry of Health of Morocco, with the support of WHO/EMRO, re-oriented its malaria control programme towards elimination. Targeted control efforts and intensified surveillance temporarily interrupted local transmission (there were only 3 local cases due to P. vivax in 2000 and zero cases in 2001) but there was an outbreak in 2002 with 19 local cases in Chefchaouen province. Subsequent interventions
Figure Box 6.5 Trends in reported malaria cases in Morocco, 1960–2010
6.7 Eastern Mediterranean RegionThere are 6 countries with areas of high malaria transmission in the
WHO Eastern Mediterranean Region (Afghanistan, Djibouti, Pakistan,
Somalia, Sudan and Yemen), 3 countries with low, geographically
limited malaria transmission and effective malaria programmes
(Islamic Republic of Iran, Iraq and Saudi Arabia) and 4 countries that
are in the phase of preventing re-introduction of malaria (Egypt,
Morocco, Oman, and the Syrian Arab Republic). P. falciparum is the
dominant species of parasite in Djibouti, Saudi Arabia, Somalia, Sudan
and Yemen, but the majority of cases in Afghanistan and Pakistan,
and a majority of cases in the Islamic Republic of Iran and in Iraq, are
due to P. vivax (Fig. 6.15b). In 2009, the Region reported a total of 5.7
million probable and confirmed malaria cases of which only 1 million
(18%) were confirmed parasitologically. Four countries accounted for
98% of the confirmed cases: Sudan, 70%; Pakistan, 17%; Afghanistan
6%; and Yemen, 5%.
1
10
100
1000
10 000
100 000
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
Num
ber o
f cas
es, l
ogar
ithm
ic sc
ale
Local
Total
Malaria eradicationprogramme
P. falciparumeliminated
Commitment toeliminate malaria
Last local case
Free status certified
Four countries reported reductions in malaria cases of more
than 50% between 2000 and 2009 (Afghanistan, Islamic Republic of
Iran, Iraq, and Saudi Arabia). Intensive control activities are carried
out in the Islamic Republic of Iran, Iraq and Saudi Arabia, and these
countries are now in the elimination or pre-elimination stage (Fig.
6.15e). Other countries in the Region have not reported consistent
decreases in the number of cases (Djibouti, Pakistan, Somalia, Sudan
and Yemen), although Sudan has extended the coverage of malaria
preventive activities to more than 50% of the population at risk
and has reported a reduction of cases in some parts of the country.
Yemen has reported no local cases on Socotra Island and a reduction
in parasite prevalence in Tihama populations. Data for Djibouti are
only available for 2004–2008 and do not show a consistent trend.
In summary, 3 countries (Islamic Republic of Iran, Iraq, Saudi
Arabia) showed evidence of a sustained decrease of more than 50%
in the number of cases since 2000, associated with widespread imple-
mentation of malaria control activities.
and intensified surveillance brought the outbreak under control and the last local case of P. vivax was recorded in 2004. Since then, the country has recorded no locally-acquired cases of malaria, but receives an average of 109 imported cases annually, of which 88% are due to P. falciparum, mainly from sub-Saharan Africa. The programme has continued to spend approximately US$ 800 000 per year for maintaining interventions since 2007, 40% of this being for free diagnosis and treatment. In 2008, four years after interrupting local transmission, procedures towards certification of the achievement of malaria elimination were initiated. The country was certified free of malaria by the Director-General of WHO in May 2010. Increasing numbers of imported cases, illegal population movements and gradual attrition of malaria programme expertise are on-going challenges for the programme in keeping the country free of malaria, and preventing its reintroduction.
BOX 6.5
CERTIFICATION OF MALARIA ELIMINATION IN MOROCCO
WORLD MALARIA REPORT 2010 55
Figure 6.15 WHO Eastern Mediterranean Region
d) Confirmed cases as a percentage of total estimated cases, 2009
e) Changes in numbers of confirmed cases, 2000–2009 countries with evidence of sustained decrease in cases
b) Percentage of cases due to P. falciparum, 2009a) Population at risk, 2009
f) Changes in numbers of confirmed cases, 2000–2009 countries with limited evidence of sustained decrease in cases
c) Annual blood examination rate, average 2000–2009
h) IRS and ITNs delivered – maximum percentage of high risk population protected: countries with limited evidence of sustained decrease in cases
0
50
100
150
200
250
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Iraq
Saudi Arabia
Iran (Islamic Republic of)
Afghanistan
0
50
100
150
200
250
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Pakistan
Somalia
Sudan
Yemen
Iraq
Saudi Arabia
0%
50%
100%
150%
200%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Iran (Islamic Republic of)
Afghanistan
High risk Low risk Malaria free
0% 20% 40% 60% 80% 100%
Iraq
Iran (Islamic Rep.)
Djibouti
Saudi Arabia
Yemen
Afghanistan
Pakistan
Somalia
Sudan
0% 20% 40% 60% 80% 100%
Iraq
Afghanistan
Iran (Islamic Rep.)
Pakistan
Saudi Arabia
Somalia
Yemen
Djibouti
Sudan
0% 10% 20% 30% 40% 50%
Djibouti
Somalia
Afghanistan
Pakistan
Yemen
Sudan
Saudi Arabia
Iran (Islamic Rep.)
Iraq
g) IRS and ITNs delivered – maximum percentage of high risk population protected: countries with evidence of sustained decrease in cases
0%
50%
100%
150%
200%
2001 2002 2003 2004 2005 2006 2007 2008
Sudan
Pakistan
Djibouti
Somalia
Yemen
0% 20% 40% 60% 80% 100%
Somalia
Yemen
Pakistan
Djibouti
Sudan
Afghanistan
Saudi Arabia
Iran (Islamic Rep.)
Iraq
56 WORLD MALARIA REPORT 2010
6.8 Western Pacific RegionMalaria transmission in the WHO Western Pacific Region is highly
heterogeneous. It is intense and widespread in the Pacific countries
(Papua New Guinea and Solomon Islands and, to a lesser extent,
Vanuatu). It is highly focal in the countries and areas of the Greater
Mekong sub-region, such as Cambodia, Yunnan (China), the Lao
People’s Democratic Republic and Viet Nam, occurring in remote
forested areas and disproportionately affecting ethnic minorities and
migrants. Malaria is restricted to particular geographical locations in
Malaysia, the Philippines and the Republic of Korea. Most countries
have both P. falciparum and P. vivax, but transmission is entirely
due to P. vivax in the Republic of Korea and central areas of China
(Fig. 6.16b).
Approximately 247 000 confirmed cases were reported from the
Region in 2009. Three countries (Papua New Guinea, 31%, Cambodia,
26% and Solomon Islands, 13%) accounted for the 71% of the
reported confirmed malaria cases in the Region, although this does
not reflect the true burden because only 13% of suspected cases
attending health facilities are given a diagnostic test in Papua New
Guinea. Five countries reported decreases > 50% in the number of
confirmed cases between 2000 and 2009 (China, the Lao People’s
Democratic Republic, the Republic of Korea, Solomon Islands, and
Num
ber o
f con
firm
ed m
alaria
case
s (in
thou
sand
s)
Cove
rage
ABE
R (%
)
0
2
4
6
8
10
12
14
2000 2001 2002 2003 2004 2005 2006 2007 2008 20090
2040
6080
100
120140
160180
200
Maximum coverage (IRS+ITNs)
Confirmed cases
Annual blood examination rate (ABER)
Malaria cases in Malaysia are concentrated in the deep forested areas of Sabah and Sarawak on the island of Borneo; the incidence is low on the mainland at less than 0.1 case per 1000 population. The number of reported cases fell from 12 705 in 2000 to 7010 in 2009, of which 8% were imported.
Figure Box 6.6 Trends in cases and malaria programme coverage in Malaysia, 2000–2009
BOX 6.6
PROGRESSING WITH PRE-ELIMINATION OF MALARIA IN MALAYSIA
Viet Nam). There is evidence of widespread implementation of malaria
control activities in all of these countries, either by vector control or
enhanced case management. Estimated coverage of vector control
interventions appears to be low in Viet Nam which may reflect the
focal nature of malaria in the country. In addition, household surveys
indicate that more than 90% of households own a mosquito net in
both Cambodia (DHS 2005) and Viet Nam (MICS 2006) although only
5% and 19% respectively sleep under an ITN. Hence, ITN coverage
derived from public sector deliveries of ITNs may underestimate
prevention efforts in these countries.
Three countries reported decreases of 25%–50% in the number
of cases between 2000 and 2009 (Malaysia, Philippines and Vanuatu)
(Fig.6.16e); there is widespread coverage of vector control inter-
ventions in Malaysia and Vanuatu. In both Cambodia and Papua
New Guinea there was little change in confirmed cases although
Cambodia reported a reduction in malaria deaths from 608 in 2000
to 279 in 2009 (54% decrease).
In summary, 5 countries showed evidence of a sustained decrease
of > 50% in the number of cases associated with large scale imple-
mentation of malaria control activities (China, Lao People's Demo-
cratic Republic, Republic of Korea, Solomon Islands, and Viet Nam).
With more than 1.5 million slides examined each year in a population at risk of approximately 1 million, the annual blood examination rate exceeds 100%; about 11% of cases are diagnosed through active case detection. Slide positivity rates have fallen from 0.7% in 2000 to 0.4% in 2008 as has the percentage of cases due to P. falciparum from 51% to 39%. In addition to early case detection and prompt treatment, Malaysia uses IRS and ITNs for malaria prevention and control. An average of 350 000 people were protected by IRS per year in 2007–2009 (35% of the population at risk) while 380 000 ITNs were delivered, sufficient to cover 75% of the population at risk assuming two people sleeping under each ITN. The NMCP is financed entirely by the Government of Malaysia. Reported expenditure in 2009 was US$ 24 million. Malaysia is in the pre-elimination phase of malaria control.
WORLD MALARIA REPORT 2010 57
Figure 6.16 WHO Western Pacific Region
d) Confirmed cases as a percentage of total estimated cases, 2009
e) Changes in numbers of confirmed cases, 2000–2009 countries with evidence of sustained decrease in cases
b) Percentage of cases due to P. falciparum, 2009a) Population at risk, 2009
f) Changes in numbers of confirmed cases, 2000–2009 countries with limited evidence of sustained decrease in cases
c) Annual blood examination rate, average 2000–2009
h) IRS and ITNs delivered – maximum percentage of high risk population protected: countries with limited evidence of sustained decrease in cases
50
0
100
150
200
250
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
ChinaLao People's Dem. Rep.
MalaysiaPhilippines
Republic of KoreaSolomon Islands
VanuatuViet Nam
0
20
40
60
80
100
120
140
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Cambodia
Papua New Guinea
0
20
40
60
80
100
2002 2003 2004 2005 2006 2007 2008 2009
Lao People's Democratic Republic
ChinaRepublic of Korea
Solomon IslandsViet Nam
High risk Low risk Malaria free
0% 20% 40% 60% 80% 100%
Republic of Korea
China
Malaysia
Philippines
Lao People's Dem. Rep.
Viet Nam
Cambodia
Papua New Guinea
Solomon Islands
Vanuatu
0% 20% 40% 60% 80% 100%
Republic of Korea
China
Malaysia
Vanuatu
Solomon Islands
Philippines
Cambodia
Viet Nam
Papua New Guinea
Lao People's Dem. Rep.
0% 10% 20% 30% 40% 50%
194%
77%
Republic of Korea
China
Philippines
Cambodia
Viet Nam
Papua New Guinea
Lao People's Dem. Rep.
Vanuatu
Solomon Islands
Malaysia
g) IRS and ITNs delivered – maximum percentage of high risk population protected: countries with evidence of sustained decrease in cases
0
20
40
60
80
100
2002 2003 2004 2005 2006 2007 2008 2009
Papua New Guinea
Vanuatu
Cambodia
Philippines
0% 10% 20% 30% 40% 50% 60% 70% 80%
Papua New Guinea
Cambodia
Vanuatu
Lao PDR
Philippines
Viet Nam
Malaysia
China
Republic of Korea
Solomon Islands
58 WORLD MALARIA REPORT 2010
6.9 Malaria elimination and prevention of reintroductionThere has been continued progress towards malaria elimination
in several countries in 2009 and 2010. Uzbekistan reported zero
locally acquired cases in 2009 and no locally acquired P. falciparum
cases were reported from the European Region in 2009. Morocco and
Turkmenistan were certified free of malaria in 2010 and Cape Verde
entered the pre-elimination stage in 2010. Figure 6.17 shows the
current classification of countries in the pre-elimination, elimination
and prevention of reintroduction phases as of 1 December 2010.
For certification to be accorded, a defensible, plausible argument
has to be made that, beyond reasonable doubt, the chain of local
human malaria transmission by Anopheles mosquitoes has ended in
the entire country at a given time, and that good quality surveillance
systems are in place and capable of detecting local transmission if
it occurred. The burden of proof of elimination falls on the country
requesting certification. Inspection and evaluation are carried out by
a team of experts led by WHO. The team makes a recommendation on
certification based on an assessment of the current situation and the
likelihood that elimination can be maintained. The final decision on
granting certification rests with the WHO Director-General. Countries
that obtain certification are added to the WHO Official Register of
areas where malaria elimination has been achieved, and the certifica-
tion is published in the WHO Weekly Epidemiological Record.
A total of 27 countries and territories have gone through the certi-
fication process over the past 27 years and are entered in the WHO
Official Register as having eliminated malaria (Table 6.3). Certified
countries continue reporting on an annual basis to WHO on the main-
tenance of their malaria-free status. Outbreaks of falciparum malaria
in a normally or recently malaria-free country are reported to WHO
immediately, so that WHO can provide assistance where needed and
can alert international travellers visiting the affected areas that they
should take suitable preventive measures. To protect international
travellers, WHO posts reports of falciparum malaria outbreaks in
“malaria-free” countries in the Weekly Epidemiological Record and on
the International travel and health web site (www.who.int/ith).
An indication of the re-establishment of transmission would be
the occurrence of three or more malaria infections that are linked
in space and time to mosquito-borne transmission in the same
geographical focus within the country, for two consecutive years
for P. falciparum, and for three consecutive years for P. vivax. WHO
reports such instances in the annual updates of International travel
and health. The risk of re-establishment of transmission fluctuates
with the degree of importation of parasites into an area (vulnerabil-
ity), the likelihood that imported parasites will encounter favourable
conditions for onward transmission (receptivity), and the watchful-
ness of the public health services for any occurrence of malaria in an
area in which it had not existed or from which it had been eliminated,
and the application of necessary measures against it (vigilance).
Over the period 1981–2007, the 11 countries in the European
Region that were certified as having achieved malaria elimination
reported a total of 35 754 imported malaria cases, i.e. 1324 cases
annually on average (range: 728–2222). Almost half of these cases
were reported by Italy (15 180, i.e. 562 annually on average, range
143–1006). Despite this high importation rate, Italy had only two
instances of local transmission: one case in 1997 and two cases in
2007, all due to P. vivax.
The other country in this group with local mosquito-borne trans-
mission since 1981 is Bulgaria: a total of 18 P. vivax malaria cases
occurred in 1995–1996. Currently the most vulnerable country in the
Register is the United Arab Emirates, which reported 18 240 imported
malaria cases over the period 1999–2008 (range: 1322–2629 per
year), linked to the high numbers of immigrant workers originating
from endemic countries. For 2008, the importation rate amounted
to nearly 6 malaria cases per 10 000 inhabitants, in a population of
4.485 million people. No local transmission has been reported in the
United Arab Emirates since 1997.
6.10 Global estimates of malaria cases and deaths, 2000–2009
6.10.1 Methods
The global number of malaria cases in 2000–2009 was estimated
by one of two methods.
1. Countries outside the WHO African Region and low transmission
countries in Africa6. Estimates of the number of cases were made
by adjusting the number of reported malaria cases for complete-
ness of reporting, the likelihood that cases are parasite-positive
and the extent of health service use. The procedure, which is
described in the World Malaria Report 2008 (10), combines data
reported by NMCPs (reported cases, reporting completeness, like-
lihood that cases are parasite positive) with those obtained from
nationally representative household surveys on health service use.
If data from more than one household survey was available for a
country, estimates of health service use for intervening years were
imputed by linear regression. If only one household survey was
available then health service use was assumed to remain constant
over time; analysis summarized in the World Malaria Report 2008
indicated that the percentage of fever cases seeking treatment
in public sector facilities varies little over time in countries with
multiple surveys. For some countries NMCP data were missing or
considered unreliable for selected years during the past decade (a
total of 64 country years out of 690 country years). In such cases an
estimate of the number of cases was constructed by sampling from
the estimates for neighbouring years. Such a procedure results
in an estimate that shows little change over time but which also
produces a wide uncertainty interval around the point estimate.
2. Other countries in the WHO African Region. For some African
countries the quality of surveillance data did not permit a convinc-
ing estimate to be made from the number of reported cases.
For these countries, an estimate of the number of malaria cases
was derived from an estimate of the number of people living at
high, low or no risk of malaria. Malaria incidence rates for these
populations are inferred from longitudinal studies of malaria
incidence recorded in the published literature. Incidence rates are
adjusted downward for populations living in urban settings and
6. Botswana, Cape Verde, Eritrea, Madagascar, Namibia, Swaziland, South Africa, and Zimbabwe.
WORLD MALARIA REPORT 2010 59
On 19 October 2010, Turkmenistan was added to the WHO Official Register of areas where malaria elimination has been achieved. Turkmenistan is the third country to be added to the list, after Morocco and the United Arab Emirates, since WHO certification procedures were re-initiated in 2004, after being abandoned in the 1980s.
By 1952 malaria in Turkmenistan was eliminated "as a major public health problem", and P. falciparum disappeared completely by the late 1950s. Over the period 1960–1980, sporadic cases of local P. vivax transmission were reported, and there was an increasing trend in imported malaria originating in Afghanistan during the 1980s. In the 1990s, the situation deteriorated because of neglect of the malaria problem and increased population movement. In 1998, 108 cases of malaria were detected in Kushka (now Serhetabad) etrap (district) of Mary velayat (province). To contain this outbreak, the most severe since 1960, the sanitary epidemiological service carried out emergency measures focussing on IRS and seasonal chemoprophylaxis.
In the 10 years 1999–2008, a total of 150 malaria cases were detected in Turkmenistan. The majority (78.6 %) of these occurred in relatively high risk areas in Mary (62 cases) and Lebap (56 cases) velayats (Tedjen-Murgab estuary and valley and Amudarya valley). The last autochthonous cases (i.e. acquired in Turkmenistan) were registered in 2004, and resulted in all probability from infections acquired during the 2002 or 2003 transmission seasons. By 2007, the Ministry of Health and Medical Industry decided to aim for certification of elimination, and in 2009, after 4 years without local transmission, procedures towards certification of the achievement of malaria elimination were launched. After following WHO standard operating procedures that include intensive external evaluation, certification was granted in October 2010.
COUNTRY/AREA REGISTRATION
Bolivarian Republic of Venezuela (northern part) June 1961
Grenada and Carriacou November 1962
Saint Lucia December 1962
Hungary March 1964
Spain September 1964
Bulgaria July 1965
China, Province of Taiwan November 1965
Trinidad and Tobago December 1965
Dominica April 1966
Jamaica November 1966
Cyprus October 1967
Poland October 1967
Romania October 1967
Italy November 1970
Netherlands November 1970
United States of America and its outlying areas of Puerto Rico and the Virgin Islands November 1970
Cuba November 1973
Mauritius November 1973
Portugal November 1973
Former Socialist Federal Republic of Yugoslavia November 1973
France, Reunion March 1979
Australia May 1981
Singapore November 1982
Brunei Darussalam August 1987
United Arab Emirates January 2007
Morocco May 2010
Turkmenistan October 2010
1. Up to 1987, the Register was known as the WHO Official register of areas where malaria eradication has been achieved.
TABLE 6.3
COUNTRIES ENTERED INTO THE WHO Official register of areas where malaria elimination has been achieved1
BOX 6.7
CERTIFICATION OF MALARIA ELIMINATION IN TURKMENISTAN
PRE-ELIMINATION ELIMINATIONPREVENTION OF RE-INTRODUCTION
Certified malaria-free and/or no ongoing local transmission for over a decade
Argentina Algeria Bahamas
Cape Verde Azerbaijan Jamaica
El Salvador Georgia Morocco Morocco
Paraguay Iraq Oman
Iran (Islamic Republic of) Kyrgyzstan Russian Federation
Malaysia Republic of Korea Syria
Mexico Saudi Arabia Armenia
DPR Korea Tajikistan Egypt
Sri Lanka Turkey Turkmenistan Turkmenistan
Uzbekistan
Figure 6.17 Movement of countries between types of programme, 2009 and 2010
In 2009, there were 8 countries in the pre-elimination stage; a ninth country, Cape Verde, was added in 2010. Morocco and Turkmenistan were certified as
free of malaria by the Director-General of WHO in 2010.
60 WORLD MALARIA REPORT 2010
the expected impact of ITN and IRS programmes. The procedure
was initially developed by the RBM Monitoring and Evaluation
Reference Group in 2004 (1) and also described in World Malaria
Report 2008 (10).
The number of malaria deaths was estimated by one of two
methods:
1. Countries outside the WHO African Region and for low transmission
countries in Africa7. The number of deaths was estimated by multi-
plying the estimated number of P. falciparum malaria cases by a
fixed case fatality rate for each country as described in the World
Malaria Report 2008 (10). This method is used for all countries
outside the African Region and for countries within the African
Region where estimates of case incidence were derived from
routine reporting systems and where malaria causes less than 5%
of all deaths in children under 5 as described in the Global Burden
of Disease Incremental Revision for 2004 (11). A case fatality rate of
P. falciparum cases
for P. falciparum cases in other Regions. In situations where the
fraction of all deaths due to malaria is small, the use of a case
fatality rate in conjunction with estimates of case incidence was
considered to provide a better guide to the levels of malaria
mortality than attempts to estimate the fraction of deaths due to
malaria.
2. Other countries in the WHO African Region, and Somalia and Sudan
in the Eastern Mediterranean Region. Child malaria deaths were
estimated using a verbal autopsy multi-cause model (VAMCM)
developed by the WHO Child Health Epidemiology Reference
Group (CHERG) to estimate causes of death for children aged
1–59 months in countries with less than 80% of vital registration
coverage. The VAMCM is a revised model based on work described
elsewhere (12,13). With an updated systematic review and addition
of vital registration data from similar settings, the VAMCM now
includes 123 study data points from 33 countries that meet the
inclusion criteria . These data are mainly from high mortality and
lower income countries. The VAMCM derives mortality estimates
for malaria, as well as eight other causes (pneumonia, diarrhea,
congenital malformation, other neonatal causes, injury, meningitis,
measles, and other causes) using multinomial logistic regression
methods to ensure that all 9 causes are estimated simultaneously
with the total cause fraction summing to 1. The regression model
is first constructed using the study-level data and then populated
with year 2000–2009 country-level input data to provide time-
series estimates of causes of death in children aged 1–59 months.
Deaths were retrospectively adjusted for coverage of ITNs and use
of Haemophilus influenzae type b vaccine. The method for esti-
mating uncertainty differs from previously published work. The
current round of estimates for 2000–2009 employs the bootstrap
method to estimate uncertainty intervals by re-sampling from
the study-level data to estimate the distribution of the predicted
percent of deaths due to each cause.
6.10.2 Disease burden and trends
Cases. In 2009 there were an estimated 225 million cases of malaria
(5th–95th centiles, 169–294 million) worldwide (Table 6.4). down from
an estimated 244 million cases in 2005. The global number of cases
was estimated to have increased between 2000 and 2005 in line with
population growth and decreased subsequently due to the impact of
malaria control. The largest percentage reductions since 2005 were
estimated to have occurred in the European Region (86%) followed
by the Region of the Americas (42%) The vast majority of cases in
2009 (78%) were in the African Region, followed by the South-East
Asia (15%) and Eastern Mediterranean Regions (5%).
Numbers for years prior to 2009 have been updated from previous
publications. They are largely consistent with those given in the World
Malaria Report 2009 (14); they are accompanied by large uncertainty
intervals, which overlap those of estimates published in previous
years reports. Any differences with previously reported numbers, as
observed for the Eastern Mediterranean and South-East Asia regions,
should not be interpreted as evidence of a change in malaria burden
but merely revisions to estimates which take into account updates
to the number of reported cases or new household survey informa-
tion.
Deaths. The global number of malaria deaths is estimated to have
decreased from 985 000 in 2000 to 781 000 in 2009. The largest
percentage decreases were seen in the Region of the Americas (48%);
the largest absolute decline was observed in the African Region. It
is estimated that 91% of deaths in 2009 were in the African Region,
followed by the South-East Asia (6%) and Eastern Mediterranean
Regions (2%). About 85% of deaths globally were in children under
5 years of age. The estimated numbers of deaths for prior years are
consistent with those reported in the World Malaria Report 2009 but
are lower in the African Region principally because the effects of
increased intervention are taken into account. The number of deaths
in the South-East Asian Region is higher than previously estimated
owing to increased estimates in India and Indonesia. The estimates
are accompanied by large uncertainty intervals, which overlap those
of previous estimates.
6.11 Conclusions
Reductions in malaria admissions and deaths in Africa. A total of
11 countries in the WHO African Region showed more than 50%
reduction in either confirmed malaria cases or malaria admissions
and deaths (Table 6.1). In all countries the decreases are associ-
ated with intense malaria control interventions. The trends shown
in data routinely collected by NMCPs are consistent with those
found in research studies in eastern, central and southern Africa (e.g.
Eritrea, Equatorial Guinea, Ethiopia, Kenya, Rwanda, South Africa, UR
Tanzania) and in the Gambia (15–21).
Resurgences in cases in Africa. There was evidence of an increase
in malaria cases in three countries in 2009 that had previously
shown decreases (Rwanda, Sao Tome and Principe, and Zambia).
The reasons for these resurgences are not known with certainty. In
Rwanda, national-level rainfall and temperature anomalies were
7. Studies conducted in 1980 or later with a multiple of 12 months study duration, cause of death available for more than a single cause, with at least 25 deaths in children <5 years of age, each death represented once, and less than 25% of deaths due to unknown causes. Studies conducted in intervention groups in clinical trials, and verbal autopsy studies con-ducted without use of a standardized questionnaire or with inadequate description of methods were excluded from the analysis.
WORLD MALARIA REPORT 2010 61
not associated with the resurgences. There was increased rainfall
in Zambia, 2007–2008, but the increase in cases was pronounced in
only two provinces. In Rwanda and Zambia a substantial proportion
of ITNs were distributed 2–3 years before the resurgence and it is
possible that the effectiveness of ITNs had become reduced owing
to physical deterioration of nets and insecticide decay. Resistance to
the pyrethroid insecticides used in ITNs is also a possible explanation,
but information is not readily available as few countries undertake
regular monitoring of insecticide resistance.
Actions needed to prevent and contain resurgences. Increases in
malaria cases highlight the fragility of malaria control and the need
to maintain control programmes even if numbers of cases have
been reduced substantially. They also show that monthly monitor-
ing of disease surveillance data both nationally and sub-nationally
is essential. Since most countries in sub-Saharan Africa had inad-
equate data to monitor disease trends, greater efforts are needed
to strengthen routine monitoring systems. Major epidemiologi-
cal events could be occurring in other countries but are not being
detected and investigated.
Reductions of cases outside Africa. A decrease of more than 50%
in the reported number of cases of malaria between 2000 and 2009
was found in 3 of1 the 56 malaria-endemic countries outside Africa
(Table 6.3), and downward trends of 25%–50% were seen in 8 other
countries. The European Region has been the most successful with
one country certified as malaria-free in 2010 and no cases of P. falci-
parum malaria in the entire Region in 2009 for the first time. In 27 of
CASES (in thousands) 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Uncertainty boundslower upper
African 173 000 178 000 181 000 185 000 187 000 188 000 187 000 186 000 181 000 176 000 117 000 241 000Americas 2 800 2 300 2 200 2 100 1 900 1 900 1 700 1 500 1 100 1 100 1 000 1 300Eastern Mediterranean 15 000 16 000 17 000 16 000 14 000 12 000 12 000 12 000 13 000 12 000 10 000 15 000European 47 34 27 22 13 7 4 2 1 1 1 1South-East Asia 38 000 38 000 35 000 35 000 37 000 39 000 34 000 32 000 34 000 34 000 28 000 41 000Western Pacific 2 800 2 500 2 200 2 500 2 800 2 300 2 500 2 100 1 900 2 300 2 000 2 500World 233 000 236 000 237 000 241 000 243 000 244 000 238 000 233 000 231 000 225 000
lower bound 181 000 181 000 182 000 184 000 185 000 185 000 179 000 175 000 171 000 169 000upper bound 302 000 304 000 308 000 313 000 314 000 317 000 310 000 304 000 298 000 294 000
DEATHS 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Uncertainty boundslower upper
African 900 000 893 000 885 000 880 000 870 000 853 000 832 000 802 000 756 000 709 000 554 000 892 000Americas 2 400 2 300 1 400 1 400 1 500 1 600 1 600 1 400 1 100 1 300 900 1 700Eastern Mediterranean 18 000 18 000 21 000 19 000 17 000 17 000 16 000 15 000 16 000 16 000 12 000 26 000European 0 0 0 0 0 0 0 0 0 0 0 1South-East Asia 58 000 55 000 51 000 50 000 52 000 50 000 48 000 43 000 48 000 49 000 37 000 63 000Western Pacific 6 800 5 800 5 200 5 900 6 500 4 900 5 400 4 700 4 200 5 300 3 400 7 300World 985 000 974 000 963 000 957 000 947 000 927 000 904 000 867 000 826 000 781 000
lower bound 797 000 785 000 775 000 769 000 765 000 744 000 725 000 694 000 662 000 628 000upper bound 1 228 000 1 214 000 1 199 000 1 191 000 1 174 000 1 153 000 1 120 000 1 075 000 1 024 000 968 000
TABLE 6.4
ESTIMATES OF MALARIA CASES AND DEATHS BY WHO REGION, 2000–2009
the 31 countries with more than 50% decreases in reported cases,
the scale of preventive activities (ITNs and IRS) was sufficient to cover
more than 50% of the population at high risk and/or the countries
maintained strong systems for detecting and treating cases. In 5 of
the 8 countries which had a decrease of 25%–50%, this was associat-
ed with intensified intervention. In contrast, only 2 of the 15 countries
that showed no evidence of a decrease carried out large-scale imple-
mentation of malaria control activities.
Reductions in malaria outside Africa are greater in countries with lower burdens. The countries that recorded more than 50%
decreases since 2000 in the numbers of cases accounted for only
14% of the total estimated cases outside Africa in 2000 (8.3 million
cases out of 59 million estimated). The countries with the highest
malaria burdens within each Region were less successful in reducing
the numbers of cases of malaria nationally, which may be related to
smaller per capita investments in malaria control.
Significant reductions in malaria burden are estimated to have occurred since 2000. The number of cases of malaria was estimated
to have decreased globally from 244 million in 2005 to 225 million
in 2009. The number of deaths due to malaria was also estimated to
have decreased from 985 000 in 2000 to 781 000 in 2009. Decreases
in malaria burden have been observed in all WHO Regions, with the
largest percentage decreases noted in the European Region, followed
by the Region of the Americas. The largest absolute decreases in
cases and deaths were observed in Africa.
62 WORLD MALARIA REPORT 2010
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